Primary Care Codes for Payment

The technique by which Current Procedural Terminology (CPT) codes are developed so that physicians can get paid for their services and procedures is highly entangled and deserves some explanation. Furthermore, Medical Billers and Coders (MBC) is effectively occupied with this procedure and advocates for the eventual benefits of its clients, which incorporates improved payment for primary care codes and subspecialists under Medicare.

Primary Care Codes for Improved Payment

CPT codes report medical services and procedures physicians and other health care experts perform. During that time, the CPT Editorial Panel meets to audit new and existing CPT codes for approval or updating. The Relative Value Update Committee (RUC) assigns values to new CPT codes and re-examines existing codes. This advisory body recommends the value of physician services to the Centers for Medicare and Medicaid Services (CMS).

Physician payments are then made for each visit or on a per-procedure basis, as the CPT codes characterize. Most private payers adopt the values for services from CMS yet may apply diverse transformation factors.

Below is the List of Codes (ref: ACP’s Coding ) that Physicians can use:

  • 99421: Online digital evaluation and management service for an established patient for up to 7 days, the cumulative time during the 7 days; 5–10 minutes
  • 99422: Online digital evaluation and management service for an established patient for up to 7 days cumulative time during the 7 days; 11– 20 minutes
  • 99423: Online digital evaluation and management service for an established patient for up to 7 days, the cumulative time during the 7 days; 21 or more minutes

Digitally Stored Data Services/Remote Physiologic Monitoring

The two new codes—99473 and 99474—support home blood pressure monitoring, which provides valuable information physicians can use to diagnose and manage hypertension better. Home BP monitoring also helps patients actively participate in the process.

  • 99473: Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration;
  • 99474: separate self-measurements of two readings one minute apart, twice daily over 30 days (minimum of 12 readings), collection of data reported by the patient and caregiver to the physician or other qualified health care professional, with the report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient.

Remote Physiologic Monitoring Treatment Management Services

  • 99457: Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes;
  • 99458: each additional 20 minutes (List separately and code for primary procedure).

Chronic Care Management and Complex Chronic Care Management

  • G2064: Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional  time per calendar month with the following elements: One complex chronic condition lasting  at least 3 months;
  • G2065: Comprehensive care management for a single high-risk disease service, e.g., Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month with the following elements: one complex chronic condition lasting at least 3 months;
  • 99490: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month;
  • G2058: Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month;
  • 99487: Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month;
  • 99489: Each additional 30 minutes of clinical staff time is directed by a physician or other qualified health care professional, and complex chronic care management services are provided per calendar month.

Advanced Primary Care Planning

  • 99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and surrogate;
  • 99498: Advance care planning; each additional 30 minutes.

Behavioral Health Management

  • 99484: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.

Psychiatric Collaborative Care Model

  • 99492: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional;
  • 99493: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional;
  • 99494: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

Legacy AR - Medical Billers and Coders

Effective Primary Care Codes for Payment management are crucial in addressing legacy AR (accounts receivable) challenges. Legacy AR refers to aged, unpaid claims that have accumulated over time, often due to coding errors, claim denials, or delays in payment processing. By ensuring accurate use of primary care codes, including evaluation and management (E/M) codes and preventive care codes, healthcare providers can significantly reduce the backlog of unresolved claims. Streamlining coding practices improves the accuracy of claims submissions and accelerates the payment cycle, mitigating legacy AR’s impact and enhancing primary care practices’ financial stability.

Get More Help

Are you stuck on medical billing? Know what challenges in Credentialing, Charge Entry, Payment Posting, Benefits/Eligibility Verification, Prior Authorization, Filing claims, AR Follow-Ups, Old AR, Claim Denials, and resubmitting rejections with Medical Billing Companies – Medical Billers and Coders, especially when it comes to Primary Care Billing.

If your revenue cycle management processes hinder your ability to provide these services, contact us at MBC to learn how we can help. Our experienced teams can alleviate medical coding,  and billing concerns so you can focus more on patients.

FAQs

1. What are Primary Care Codes?

Primary Care Codes are specific medical billing codes used to document and bill for services provided by primary care physicians. These codes include evaluation and management (E/M) codes, preventive care codes, and various procedure codes, ensuring that healthcare providers are accurately compensated for their services.

2. Why are Primary Care Codes necessary for payment?

Primary Care Codes are crucial for payment because they standardize the billing process, making it easier for insurance companies to understand and process claims. Accurate coding helps avoid claim denials, ensures proper reimbursement, and reduces the chances of revenue loss due to coding errors or omissions.

3. How can primary care codes help reduce legacy AR?

Primary Care Codes can significantly reduce legacy AR (accounts receivable) by ensuring that claims are correctly coded and submitted on time. Accurate coding reduces the likelihood of claim denials and delays, facilitating faster payment and minimizing the accumulation of unpaid allegations that can negatively impact a practice’s financial health.

4. What common challenges do providers face with Primary Care Codes?

Common challenges include staying updated with code changes, ensuring accurate documentation, avoiding upcoding or under coding, and managing complex coding scenarios for patients with multiple conditions. If not managed effectively, these challenges can lead to claim denials, delayed payments, and increased administrative burdens.

5. How can healthcare providers stay compliant with Primary Care Codes?

Healthcare providers can stay compliant by regularly training their staff on the latest coding guidelines, utilizing coding software and resources, conducting periodic audits to ensure accuracy, and staying informed about changes in coding regulations. Partnering with a specialized medical billing company can help manage compliance and streamline the billing process.