Healthcare Fraud Shield’s Latest Article: Are you ready for the 2020 Code Updates?

6 Jan
Every year around September, the AMA releases their annual code set changes for the following year. There are 394 code changes effective January 1, 2020 which includes 248 new codes, 75 revisions and 71 deletions.
It’s important to familiarize yourself with the new code set changes. Let’s take a look at some of the changes and the potential schemes they bring with them.

Online Digital Evaluations or E-visits
Six new codes for reporting online digital evaluation services, or e-visits will be introduced in 2020. These codes cover patient-initiated digital communications with a physician or other qualified healthcare professional (99421, 99422, 99423) or a non-physician healthcare professional (98970, 98971, 98972).
Potential Scheme:
Schemes could occur with upcoding the level of service or the type of healthcare professional rendering the services.

Two new vaccine codes have been established, 90694 for reporting Influenza virus vaccine for intramuscular use, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, and code 90619 for reporting meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier for intramuscular use.
Potential Scheme:
CPT 90694 carries the   symbol advising that this vaccine is pending FDA approval. Health plans may not reimburse for codes with this symbol until they are approved by the FDA. Be sure to check the FDA status of this code semiannually (July 1st and January 1st) at the AMA CPT website: under the CPT Category I vaccine codes.

Two new codes (90912-90913) have been added for reporting biofeedback training, perineal muscles, including EMG and/or manometry when performed.
Potential Scheme:
CPT 90912 is used for the first 15 minutes of one-on-one physician or other qualified healthcare professional contact with the patient for biofeedback training. CPT code 90913 is an add-on code used for each additional 15-minute increment. Since these codes represent personal contact with the patient, look for providers treating more than one patient at a time or excessive units of service.
Self-Measured Blood Pressure Monitoring
The 2020 code updates include the addition of CPT codes:
99473-patient education and calibration of home BP device); and
99474-separate self-measurements of two readings one minute apart, twice daily over 30-day period.

Potential Scheme:
Look for providers inappropriately billing CPT code 99473 more than once per device/patient, and CPT code 99474 being reported more than once per calendar month.

Health and Behavioral Assessments and Intervention Services
In order to more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings the AMA is incorporating new codes for health and behavior assessment and intervention services (96156, 96158, 96164, 96167, 96170 and add-on codes 96159, 96165, 96168, 96171) to replace 6 older codes.
Potential Scheme:
Health behavioral Assessments are conducted through health-focused clinical interviews, observation and clinical decision making. Health Behavioral Interventions emphasize active patient/family engagement and involvement. Look for the same provider billing evaluation and management codes including counseling risk factor reduction and behavior change intervention (99401-99421) on the same day as health behavior assessment and intervention codes, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170 and 96171 as this is generally considered inappropriate.

Long term electroencephalographic (EEG) Monitoring services
According to the AMA, one of the major changes coming in 2020 involves a significant enhancement to the codes for reporting long term electroencephalographic (EEG) monitoring services (95700-95726).
  • Deletion of CPT Codes 95950, 95951, 95953, 95956
  • Creation of 10 Professional Component Codes(for physician work only)
  • Creation of 13 Technical Component Codes (no physician work included)
    • Unmonitored – or more than 13 patients monitored concurrently
    • Intermittent monitoring – between five and 12 patients concurrently
    • Continuous monitoring – four or fewer patients concurrently
    • 95701 – Set up code (includes take down)
Potential Scheme:
Review claims and medical records for indications the provider is billing set up/take down code 95700 more than one time per recording. Patient placed electrode sets should be reported with code 95999. Confirm through the medical records that the correct code is being used for professional versus technical services, EEG with or without video, the monitoring and duration of testing.
In addition to the changes mentioned, additions, revisions and deletions are also being introduced in several other areas including:
  • Evaluation and Management
  • Surgery
  • Radiology
  • Pathology and lab
  • Medicine
  • Category II and III
Look for more code changes for 2020 in our upcoming Articles in 2020.
If you have any questions or comments, please contact


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