The 2019 Medicare Documentation, Coding, and Payment Update

Kent Moore; Amy Mullins, MD, CPE, FAAFP; Erin Solis; Barbara Hays, CPC, CPMA, CPC-I, CEMC


Fam Pract Manag. 2019;26(1):23-28. 

In This Article

Coding Changes

This year's CPT and HCPCS coding changes cover a wide array of services, from chronic care management to virtual encounters. (See a brief summary in "New codes for 2019.")

Interprofessional telephone, internet, or electronic health record (EHR) consultations. Interprofessional telephone/internet consultation codes received an overhaul for 2019 along with the addition of two new codes. CPT codes 99446–99449 now allow time spent consulting via telephone or internet about a patient's status to also include the time required to review and analyze the EHR. Codes 99446–99449 still require a verbal interaction with the requesting physician and include the resulting written report. New codes 99451–99452 allow reporting of the same functions without the verbal consultation requirement.

Medicare does not pay for codes 99446–99449 in the nonfacility (e.g., office) setting, but codes 99451–99452 are priced in the non-facility setting. Check with your individual payers to verify whether the code set will be paid under their fee schedules.

Digitally stored data services/remote physiologic monitoring. If a patient is prescribed the use of a Food and Drug Administration-approved device to monitor physiologic issues such as weight, blood-pressure, or pulse oximetry, you can now use CPT codes to report the set-up and education for the device (99453), as well as the 30-day supply of the device (99454). To report the physician review, analysis, care plan, and documentation of these activities, use existing code 99091. Remember that 99091 is time-based and requires a minimum of 30 minutes. Also, note that CPT has moved code 99091 out of the "Medicine" section and reclassified it as an E/M service. Another new option within this realm is code 99457, remote physiologic monitoring treatment management services, 20 minutes or more per month delivered by clinical staff/physician/qualified healthcare professional, which requires interactive communication regarding the service with the patient or caregiver. Medicare will allow payment for all these codes in 2019.

Chronic care management (CCM) services. Code 99490 for CCM became a payable service under Medicare in 2015. This service is managed by a physician, but clinical staff as defined by CPT typically perform most of the CCM functions, and the service is priced accordingly. New in 2019 is CPT code 99491 for CCM services performed by a physician or other qualified health care professional, consisting of at least 30 minutes in a calendar month. The other requirements of CCM still apply.

"The higher rate for chronic care management code 99491 reflects the fact that the service is personally performed by the physician."

The 2019 Medicare allowance for code 99491 is approximately $83.97, which is higher than the allowance of $42.17 for code 99490. The higher rate for code 99491 reflects the fact that the service is personally performed by the physician rather than clinical staff under the physician's supervision. Check with other payers for their coverage determinations and corresponding payment policy.

Skin biopsy services. CPT now provides definitions to help guide code selection for different types of skin and mucous membrane biopsies. Biopsy code 11100 and add-on code 11101 have been deleted. There are three types of biopsies for consideration: tangential, punch, and incisional. Tangential biopsies equate to shaving, scooping, saucerizing, or curetting the lesion (code 11102 for a single lesion and +11103 for each separate/additional lesion). Punch biopsies require the use of a punch tool to remove a full thickness cylindrical skin sample (code 11104 +11105). An incisional biopsy uses a sharp blade to remove a full-thickness sample delving through the dermis into the subcutaneous tissue (code 11106 +11107). Simple closure is included in all these codes. The definition of a biopsy has not changed: obtaining a sample of the lesion for pathological review and determination.

Medicare national average allowances in the nonfacility (e.g., office) setting are as follows:

  • Tangential biopsy (11102 +11103): $100.91 and $54.42, respectively,

  • Punch biopsy (11104 +11105): $126.86 and $62.35, respectively,

  • Incisional biopsy (11106 +11107): $153.53 and $73.52, respectively.

New vaccine code. Only one new vaccine code has been added for 2019:

Code 90689, Influenza virus vaccine, quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25mL dosage, for intramuscular use.

For payment details, consult the Medicare Average Sales Price website and check with other payers to whom you may be submitting claims for this vaccine.

Virtual encounters. Many physicians spend time delivering historically nonbillable services such as telephone and portal encounters with patients. CMS now has a billable code for these services: HCPCS code G2012, Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report E/M services, provided to an established patient, with five to 10 minutes of medical discussion. The service must not originate from a related E/M service provided within the previous seven days nor lead to an E/M service or procedure within the next 24 hours or at the soonest available appointment time.

Similar to G2012 is new code G2010, Remote evaluation of recorded video or images submitted by an established patient (e.g., store and forward), including interpretation and follow-up with the patient within 24 business hours. Again, the service must not originate from a related E/M service provided within the previous seven days nor lead to an E/M service or procedure within the next 24 hours or until the soonest available appointment.

Note that these G-codes are created and governed by CMS and are not mandated for use by commercial payers. Some payers other than Medicare may consider them for payment, but payment is not guaranteed; therefore, practices should verify whether these codes are included in a payer's fee schedule before delivering services.