03/26/2024

New Medicare G codes and their role in Ophthalmology Care in 2024

 

By Diane E. Zucker, M.Ed., CCS-P
Health Care Management Consultant

 

Medicare has created additional codes to support the clinical work provided to patients with a variety of issues from assessment of Social Determinants of Health (SDoH) to a complexity add on code and caregiver training care that may be appropriate in the Ophthalmology setting. These new services will require informed consent by the patient, or their legal guardian is important as well. For services that span an entire month, one will need to create a method for documenting the training or support and capture the total time per month for accurate billing and coding. The following is a summary of the new coding process and how they may be used in Ophthalmology practices for Medicare and Medicare Advantage Patients.

The first new coding opportunity is for the assessment of a patient’s status for social determinants of health. Social determinants of health are non-medical factors that influence health care outcomes. They are broken down into five areas: healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment. The assessment process will use standardized tools to determine if the patient has issues in any of these areas. If a patient was identified to have an issue with a specific area, then the appropriate Z code from ICD 10 Chapter 21 would be appended. When issues are identified the provider would create a plan for management, which may include referral, monitoring, or other interventions.

The assessment process is coded with G0136 as detailed below:

The Code   G0136 $17.57 (Ohio)	Definition   G0136 Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes
Who can use the code	MD, DO, APN, CNS, PA, independently licensed mental health providers. This can be provided incident to by trained support staff, such as a vision technician.
ICD 10 Considerations	If positive SDoH are identified, then the specific ICD 10 codes within the Z code section (Chapter 21) should be specifically identified.
Documentation Considerations	A physician or other qualified health care professional administers an assessment of an individual's social determinants of health (SDOH) or identified social risk factors that may influence the diagnosis and treatment of medical conditions. SDOH can limit the provider's ability to diagnose or treat a condition and the patient's ability to follow the prescribed treatment plan. This service is reported in addition to an E/M service or the annual wellness visit (AWV). This service may only be reported once every six months. This service is approved by Medicare as a telehealth service and may be performed by staff under incident-to guidelines.   This is not a screening but an assessment, and it is to be used when the practitioner believes that the patient has unmet SDOH needs that are interfering with the diagnosis or treatment of an illness. The specific tools used to assess these issues should be identified as well as the total time involved in this activity.   This is not to be done more often than every 6 months.” The risk assessment is in relation to the patient’s social risk factors that influence the diagnosis and treatment of medical conditions. This is a service that can be performed in outpatient settings, with the exception of discharge visits/planning.   This assessment would be appropriate in a condition or situation where there may be functional changes impacting the patient’s independence. Examples might be an acute retinal detachment, progressive vision changes or a new diagnoses of a vision issue with the potential for vision loss.

 

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Things to consider in Ophthalmology would be:

• What specific areas would be pertinent to vision care – this may include transportation as well as self care concerns.
• The EMR would need to be modified to include an assessment component as part of the care when pertinent to social determinants of health for an assessment of the five areas.
• When the SDoH is positive there should be a plan in place to support these issues with identified referrals and/or other considerations.
• This assessment will tie into other new coding processes in 2024 for treatment planning for care, training, and support.

Visit complexity is inherent in many patient conditions and with the new coding process can be added on based on the specific issues involved, the care plan needs. The patient that would qualify for this additional service would be a patient with an array of health and social issues that need intervention, planning, and support to achieve the goals for better health and wellbeing. This would be a condition or constellation of issues that require additional work, coordination of care and planning. The coding is as follows:

The Code   G2211 $15.66	Definition Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established). This could be added to either the 9921x series of codes or the 920xx series of codes.
Who can use the code	Any medical provider – MD, DO, APN, PA that provides continual and ongoing support and care. This would not be used for episodic care unless that care involved continual (Longitudinal) issues.
ICD 10 Considerations	The diagnoses would identify a chronic condition with issues or concerns.
Documentation Considerations	This add-on code represents the additional time and resources associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a serious or complex condition for a new or established patient. The relationship between the provider and the patient must be ongoing to provide consistency and continuity for the patient's acute or chronic health conditions over a long period of time. Medical conditions managed by the single provider may span a broad spectrum of diagnoses and organ systems. The provider's continued responsibility for the patient's health care needs increases the complexity of the evaluation and management service. Report this code in addition to an office or outpatient evaluation and management (E/M) code.   This acuity coding would be appropriate in those cases where there may be complex decisions around procedures and the care plan. This could be related to an acute trauma, acute vision loss issues, or chronic issues that have progressed in nature requiring a wholistic approach to care (diabetic retinopathy, or vision issues post stroke are good examples)

 

Things to consider in Ophthalmology would be:

• Certain diagnoses may support this process when the acuity of issues requires coordination of care, a longitudinal care plan as in case with deterioration of vision or progressive eye disease that may impact the functional status of a patient.
• The EMR process would need to identify within the assessment and plan what makes the encounter complex in nature, beyond just the diagnoses with a narrative on the complexity issues.
• This add on cannot be coded with any other procedures codes (joint injections, debridement, etc.)
• E/M visit complexity add-on reflects the time, intensity, and PE resources involved when practitioners furnish the kinds of O/O E/M office visit services that enable them to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single high-risk disease) and to address the majority of patients’ health care needs with consistency and continuity over longer periods of time. In response to comments, we also made further refinements to the HCPCS code descriptor to clarify that the code applies to a serious condition rather than any single condition.
• The assessment and plan should be specific as to why the visit and condition was complex in nature and the needs of the patient and care provided that supported this (there are no assumptions by diagnoses or type of provider that this would be appropriate).
• The assessment should include a follow up care plan as part of this process that is specific in timing, plan, and care needs (not PRN).

Family and caregiver education and support is often needed to help support the patient in their ongoing care needs. This specific process would be geared to the caregiver and provide education, support, direction, and ideas for patient care. The codes for the group process are as follows:

The Code   96202 $22.47           96203 $5.42	Definition   96202 Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes   Face-to-face training with multiple sets of parent(s)/guardian(s)/caregiver(s) of a patient with a mental or physical health condition.   Each additional 15 minutes
Who can use the code	MD, DO, APN, PA and is not incident to so a provider would need to be involved with family education.
ICD 10 Considerations	The specific ICD 10 code would be specific to the condition for training with the identified Z codes or specific physical condition ICD 10 codes.
Documentation Considerations	The physician or other qualified health care professional provides face-to-face behavior management or modification training to multiple sets of parents, guardians, or caregivers for the patient (who is not present). The physician trains guardians and caregivers with evidence-based strategies and procedures targeted toward the patient's mental or physical health diagnosis and adverse behaviors. The training is intended to equip guardians and caregivers with skills and methods to utilize with the patient with a goal of eliciting more positive behaviors and improved health and well-being. Behavior modification focuses on changing behavioral patterns over the long-term using different motivational methods. Report 96202 for the initial 60 minutes of face-to-face time and 96203 for each additional 15 minutes.   This requires a specific plan of action, training goals and objectives in the group setting.

 

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Things to consider in Ophthalmology:

• This group service may not be common in your practice setting but in thinking outside of the box, it may be a service provided by an APN or PA to help support patients and their caregivers with the adaptation to vision loss. This may be scheduled once a month for those with a new diagnosis that has long term functional concerns. This is something that many sight centers provider that may be adapted to the private practice setting.
• The EMR could create a note template that identifies the specific goals and objectives of the training and support for the caregivers around the specific topic (diagnoses) needs. An example would be vision changes due to a stroke with education for the family around issues for adaptation of environment for long and short term adjustment.
• Support for caregivers who are assisting a relative/friend with progressive vision loss or planning for the eventual loss of vision.
• The training should be directly relevant to the person-centered treatment plan for the patient in order for the services to be considered reasonable and necessary under the Medicare program. Each behavior should be clearly identified and documented in the treatment plan, and the caregiver should be trained in positive behavior management strategies. In terms of frequency, CMS identified “In other words, the medical necessity of CTS for the patient should determine the volume and frequency of the training.” There may be instances in which the patient has a new caregiver who needs the training. The volume and frequency for the same patient may be based on the treatment plan, changes in the patient’s condition, the diagnosis, or the caregivers.
• A treatment plan is required detailing the services provide included informed consent by patient with identified caregiver - the treatment plan would include:
  • Identify the issues the patient has that the caregiver is managing.
  • Identify the specific goals for the caregiver with the patient and what steps are needed to achieve these goals.
  • What is the timeframe for this process?
  • Topics for training may include” behavior, identifying triggers, reinforcers, strategies, specific skills, functional communication, self-help, attention, and tasks.
  • What are the barriers for the patient (transportation, illness, family issues) to achieve these goals with the caregiver?
  • What resources and support will be provided
  • For each encounter documentation of care and time involved

Individual caregiver training is for the one-on-one intervention with a provider (MD, DO, APN, PA, PT, OT, SLP) to collaborate with these individuals on care plans, strategies, and methods for the patient in their lives. The coding would be with the identified “PT” codes and therefore require time documentation as well as a formal treatment plan:

The Code   97550 $50.46     97551 $25.18   97552 $20.70	Definition   97550 Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face; initial 30 minutes   Each additional 15 minutes   97552 Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face with multiple sets of caregivers
Who can use the code	MD, DO, APN, PA, OT, PT and SLP   Not provided incident to
ICD 10 Considerations	Specific ICD 10 coding that reflects the severity of the condition with functional issues specifically coded.
Documentation Considerations	Caregiver training is provided without the patient present to teach the caregiver how to facilitate a patient's functional performance in the home or community. The face-to-face training is a structured educational process aimed at equipping the caregiver with the knowledge and skills necessary to support and enhance the independent daily functioning of individuals requiring care. This training encompasses a range of practical strategies and techniques tailored to the specific needs and challenges of the patient, enabling the caregiver to create a safe, conducive, and empowering environment that promotes the patient's well-being, autonomy, and successful engagement in various activities of daily living. Report 97550 for the first 30 minutes of training. Report 97551 for each additional 15 minutes.

 

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Things to consider in Ophthalmology:

• This service may be rare in most private practices as it does duplicate what a Sight Center may provide, but in a practice that is providing a more comprehensive care model it could be provided by a contracted CNS, APN or even PT/OT for caregiver training around issues of visual impairment and care needs.
• The EMR can create templates for this training with specific goals and objectives around adaptations needed to accommodate vision issues (examples may be acute vision loss or progressive vision loss).
• Caregiver training is direct, skilled intervention for the caregiver(s) to provide strategies and techniques to equip caregiver(s) with knowledge and skills to assist patients living with functional deficits. Codes 97550, 97551 are used to report the total duration of face-to-face time spent by the qualified health care professional providing training to the caregiver(s) of an individual patient without the patient present. Code 97552 is used to report group caregiver training provided to multiple sets of caregivers for multiple patients with similar conditions or therapeutic needs without the patient present.
• A therapy plan is in place with specific goals, objectives, with time identified.
• During a skilled intervention, the caregiver(s) is trained using verbal instructions, video and live demonstrations, and feedback from the qualified health care professional on the use of strategies and techniques to facilitate functional performance and safety in the home or community without the patient present. Skilled training supports a caregiver’s understanding of the patient’s treatment plan, ability to engage in activities with the patient in between treatment sessions, and knowledge of external resources to assist in areas such as activities of daily living (ADLs), transfers, mobility, safety practices, problem solving, and communication.
• 97550-97552 are sometimes therapy codes also provided by MD, DO, APN as well as PT, OT, SLP.

In an Ophthalmology setting the G0136 Social Determinants of Health assessment and the G2211 for visit complexity will be the most common new codes appended to the E/M or Ophthalmology coding and service. These two services are probably being provided in your practices today but distinct documentation within the Assessment/Plan section of your documentation would be supported for additional coding and reimbursement. As you consider adding these services your EMR should be able to create methods to help document this care appropriately.

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