Update Details Coding for Non-face-to-face and Indirect Patient Optimization Work in the Presurgical Period

In the May 2021 issue of AAOS Now, the AAOS Coding, Coverage, and Reimbursement Committee, in conjunction with the American Association of Hip and Knee Surgeons (AAHKS), addressed correct coding for work performed prior to surgery. Various codes from the Evaluation & Management (E/M) Services section of the Current Procedural Terminology (CPT) code set were referenced, specifically office or other outpatient E/M codes and prolonged services codes. The May 2021 article reiterated what is included in the global period and was based on reporting codes to capture the physician work involved in direct interaction with the patient via telephone, electronic medical record (EMR) communication, or email, or in the office.

The November 2022 issue of the American Medical Association’s (AMA’s) CPT Assistant publication further addressed this topic in a coding brief titled “PCM Codes for Preprocedural Optimization.” The AMA states that principal care management (PCM) codes are the appropriate codes for reporting presurgical optimization management services for non-face-to-face and indirect interactions with the patient.

This article will discuss the appropriate CPT codes to report non-face-to-face and indirect services for preoptimization and provide an example of a relevant scenario in orthopaedics.

Note, the advice in this article does not supersede the May 2021 AAOS Now article. Both methods of reporting are correct, with one set of codes for reporting the preoptimization for direct patient interaction/communication and the other set of codes for non-face-to-face/indirect interaction.

Coding for indirect interactions
Orthopaedic surgeons may use code 99424, Principal care management services, for a single high-risk disease, with the following required elements:

• one complex chronic condition expected to last at least three months and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death
• the condition requires development, monitoring, or revision of disease-specific care plan
• the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities
• ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or qualified healthcare professional (QHP), per calendar month

After the initial hour, use code 99425, each additional 30 minutes provided personally by a physician or other qualified healthcare professional, per calendar month (List separately in addition to code for primary procedure.).

Code 99426 is the primary code for the first 30 minutes of clinical staff time directed by a physician or other QHP, per calendar month. Code 99427 is the add-on code for each additional 30 minutes. The required elements for these codes are the same as noted above for codes 99424 and 99425.

In addition, the CPT Assistant brief states that codes 99424 and 99425 may be reported by different physicians or other QHPs who may also report E/M services in the same calendar month for the same patient.

Clinical scenario
The following clinical scenario from the AMA explains the use of the above codes for indirect interactions prior to an elective total knee arthroplasty (TKA):

“A female patient is a candidate for elective right TKA due to osteoarthritis. She has a history of a cardiac arrhythmia and diabetes, and she lives alone. The single, complex, chronic condition is osteoarthritis of the knee. The secondary diagnoses are currently not required to be listed, but they help clarify the optimization effort.

“In order to optimize the patient’s outcome from surgery, she will need to visit her cardiologist, to participate in a diabetes clinic, and to see a case manager. The arrangements for this care coordination with these specialists and communication with these experts will need to be documented in the medical record.

“For instance, the plan for management of cardiac medication adjustments prior to surgery will need to be discussed with the cardiologist and anesthesiologist. The perioperative diabetes management will have to be coordinated. A joint education session with the planned caregiver will be needed to learn about the perioperative care. The physician, other QHP, or clinical staff documents their time to coordinate care and optimize the surgical outcomes.”

More on coding for preoperative work
AAOS and AAHKS have been engaged in the issue of coding for patient optimization work. The organizations have participated in discussions with the AMA and the Centers for Medicare & Medicaid Services (CMS), who both recognized that preservice optimization work occurs with total hip arthroplasty (27130) and TKA (27447).

Patient presurgical optimization requires ongoing communication with a care team, coordination of management of comorbidities (e.g., diabetes, hypertension), advocacy of lifestyle changes (e.g., smoking cessation), and adjustment of medications as needed. These services help minimize operative complications and maximize patient outcomes. The guidance provided in the CPT Assistant brief confirms that the work spent by physicians to establish, implement, and monitor these care plans can and should be reported.

Additionally, the CPT Assistant article addresses the following question: “Can a PCM code be reported even if there is two months of time between the surgical scheduling and the actual surgery?”

The answer is yes, according to the AMA, because the condition existed well before the scheduling of surgery and because care management and coordination occur prior to the surgical date. Work performed in the 24-hour period prior to surgery is considered the beginning of the global period for the procedure and is therefore included in the global surgical package.

AAOS members who start reporting PCM codes for patient presurgical optimization are encouraged to contact AAOS staff for reimbursement tracking purposes by emailing coding@aaos.org.

Frank Voss, MD, FAAOS, is a member of the AAOS Coding Coverage and Reimbursement Committee, as well as a CPT advisor.

John Heiner, MD, FAAOS, is vice chair of the AAOS Coding Coverage and Reimbursement Committee, as well as an alternate member to the Relative Value Scale Update Committee.

Michelle Abraham, MHA, CCS-P, is the coding and reimbursement coordinator for the AAOS Office of Government Relations.

Reference

1. American Medical Association: CPT Assistant Coding Brief: PCM Codes for Preprocedural Optimization. November 2022.