Missed billing opportunities for Medicare-related coordination codes in the primary care setting can lead to substantial losses in work relative value units (wRVU) and annual practice revenue for general internists.1 This article will raise awareness of the underutilized coordination billing codes within the SGIM community and discuss the proper utilization and documentation required when billing for these services in a primary care practice.

Tobacco Cessation

Tobacco dependence is a commonly discussed topic in primary care. Care for the tobacco user generally consists of two parts: counseling on cessation of tobacco use and lung cancer screening for smokers at higher risk. Smoking cessation counseling can be added to evaluation and management (E/M) visits but cannot be billed during the annual wellness visit (AWV). Medicare allows up to eight counseling sessions per year. There are two current procedural terminology (CPT) codes available for smoking cessation, dependent on time spent counseling: 99406 (3-10 minutes) and 99407 (> 10 minutes), and the wRVU values for these codes are 0.24 and 0.50, respectively. The following is an example of proper documentation in an outpatient progress note of smoking cessation counseling:

“I spent 5 minutes during this visit counseling patient about risks of smoking. Patient Readiness to quit smoking at this time (0-10). I discussed nicotine replacement therapy and/or medications with patient to assist with quitting. Patient information on health benefits of quitting smoking and 1-800-QUIT-NOW counseling phone number was provided.”

Lung Cancer Screening

Based on United States Preventive Services Task Force (USPSTF) Guidelines, lung cancer screening with low-dose computed tomography (LDCT) should be performed annually on individuals aged 50 to 80 years old who have a 20 pack-year smoking history and are currently smoking or have quit in the last 15 years.2 The CPT code for lung cancer screening is G0296 and the wRVU value is 0.54. This topic is most commonly covered during the Medicare or Medicare Advantage AWV, when discussion often occurs regarding other age-appropriate cancer screening such as colon, breast, and prostate cancer. The following is an example of proper documentation in an outpatient progress note for lung cancer screening counseling:

“Patient age 50-80 years confirmed. 20+ pack year smoking history confirmed. Current smoker. No acute pulmonary symptoms. Appropriate for lung cancer screening. Shared decision making occurred. Patient information provided. Open to obtain low dose CT. Order placed.”

Depression Screening

In addition to pregnant and postpartum adults, the USPSTF additionally recommends screening for depression in adults over 65 years old.2 The most utilized tool for depression screening in the primary care setting is the Patient Health Questionnaire-2 (PHQ-2) with a follow-up PHQ-9 for diagnosis and monitoring of depression. Depression screening can be performed once per year during an AWV with an associated CPT code G0444. Five to 15 minutes of counseling is required for newly diagnosed depression, and the wRVU value is 0.18. The following is an example of proper documentation of depression screening in an outpatient progress note:

“PHQ9 screening performed with patient by medical assistant and myself, each question individually answered and reviewed if needed. Staff is in place allowing for accurate diagnosis, development of treatment plans/follow up care and referral management if needed. Re-evaluate at subsequent visits. Time spent on screening 10 minutes.”

Obesity

Obesity has reached epidemic proportions in the United States. As of 2018, the USPSTF currently recommends referral to intensive, multicomponent behavioral interventions for all adults with body mass index (BMI) greater than 30. Primary care physicians can schedule up to 22 visits per year to discuss obesity with patients. A recommended follow-up schedule for obesity counseling is weekly visits for one month, biweekly for two to six months, and then monthly thereafter. The associated CPT code for obesity counseling is G0447 and requires > 15 minutes of counseling including discussion of behavioral health risks, behavioral change, treatment goals and methods, and referrals made and the wRVU value is 0.45. The following is an example of proper documentation in an outpatient progress note of obesity counseling:

“BMI of 38.5 kg/m2, stable from last evaluation. 16 minutes spent on lifestyle modifications, to include caloric restriction to 1,600–1,900 calories and increased physical activity. Dietary assessment and Intensive Behavioral Counseling and Behavioral Therapy: Work on a target of 10,000 steps per day, 150 minutes per week of light aerobic activity such as walking. Try to incorporate two days per week of light weight training. Adopt a Mediterranean diet when possible. Increase your amount of at-home meals versus eating out at restaurants. When eating away from home, make healthy decisions. Try to avoid foods/drinks with excess sugar such as soda, juices, bread, etc.”

Advanced Care Planning

Primary care providers play a crucial role in counseling regarding end-of-life goals and wishes for care. These discussions include completion of forms such as medical power of attorney, orders for scope of treatment, and do not resuscitate orders. The CPT code for advanced care planning is 99497, is applicable to any visit if it is clinically relevant, and the wRVU value is 1.5. The following is an example of proper documentation in an outpatient progress note of advanced care planning:

“16 minutes spent specifically for advance directive care planning. Importance of advanced care planning discussed with patient including DNR/DNI and other orders, Medical Power of Attorney discussed with patient. Informational packet given with advanced directive/MPOA instructions in patient native language.”

Longitudinal Care

Finally, a complex E/M code, G2211 went into effect January 1, 2024, that is applicable to Medicare and Medicare Advantage patients for longitudinal clinical care. Documentation is not specifically required, but it is wise to consider adding, “established patient, longitudinal care,” in the history of present illness or assessment sections of the progress note of that visit. This code is used exclusively during evaluation and management (E/M) visits. It may not be applied to annual wellness visits or other preventive exams, transitional care visits, or if other services are billed during the visit using a -25 modifier (e.g. a procedure). There is no limit in the number of times this code can be used in a given calendar year, and the wRVU value is 0.33.

In summary, several screening and counseling codes exist to use for Medicare patients, but these codes are often underutilized and lead to lost revenue for both internal medicine resident training clinics and attending clinical practices. Increased utilization of these codes will benefit Medicare patients that SGIM members care for as they provide needed screening services for patients (depression, lung cancer). They initiate conversations between providers and patients to help take advantage of existing community resources and initiate Advanced Care Planning conversations that can lead to better understanding of patient’s care wishes before a medical crisis. Using these screening and counseling codes also records the work provided by SGIM members and their clinical teams to show the value provided by resident and attending physicians within academic and community health systems.

References

  1. Agarwal SD, Basu S, Landon BE. The underuse of Medicare’s prevention and coordination codes in primary care: A cross-sectional and modeling study. Ann Intern Med. 2022;175(8):1100-1108. doi:10.7326/M21-4770.
  2. A&B Recommendations. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations. Accessed May 15, 2024.

Issue

Topic

Clinical Practice, SGIM

Author Descriptions

Dr. Pride (walker.pride@healthonecares.com) is a third-year resident of internal medicine at Sky Ridge Medical Center in Lone Tree, Colorado. Dr. Keller (crista.keller@healthonecares.com) is an internal medicine physician at Aspen Medical Group at Rose Medical Center in Denver, Colorado, and serves as a mentor for primary care physicians. Dr. Joy (scott.joy@healthonecares.com) is an internal medicine physician at Englewood Primary Care and Chief Medical Officer for HCA/HealthONE Continental Division in Denver, Colorado, a core faculty member for the HCA/HealthONE Internal Medicine Residency Program and an adjunct associate professor of medicine at Duke University. Ms. Parker (Elizabeth.Parker2@hcahealthcare.com) is a certified professional coder for the coding operations team of HCA corporate and supports the Continental Division as a Division Coding Consultant for PSG Primary Care and Internal Medicine practices.

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