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Coding Conundrum: SPRAVATO® (Eskatamine), Part 2
Hope Bonnetti : May 22, 2024 10:13:00 AM
Welcome back to Coding Conundrum: SPRAVATO® (Eskatamine), Part 2! In part 1 I reviewed proper reporting for Spravato®, including drug administration. All that is left to do now is cover billing opportunities for the 2-hour post-administration monitoring period. If you have no idea what I am talking about, that is cool, just go back and read Part 1 to catch up! However, if you are ready to partake in another riveting coding blog, keep on reading.
As stated previously, Spravato® patients must be monitored for at least 2 hours after administration, so surely you can account and bill for the full 2-hour time-period, right? Well, that is a possibility, but rarely is the case, unfortunately.
Going back to part 1, confirmation of insurance and benefits is crucial. If you have a Medicare patient, HCPCS code(s) G2082/G2083, includes 2 hours of post administration observation. So, nothing more needs to be done. But for non-Medicare payors who do not accept the G-codes, there are prolonged service codes available:
- Prolonged Service Codes, 99417 or G2212
- Prolonged Clinical Staff Service Codes, 99415/99416
Now you may be thinking, well this is great, we monitor the patients for 2 hours, report these codes, what is so hard about that? The codes are available, yes, but the difficult part is that you still must meet the code requirements to bill for those additional services. There is no free ride when reporting prolonged services.
Let’s first look at the provider prolonged service codes G2212 or 99417. I am not going to get into the weeds about the differences between these two codes, that is a whole other blog post, but to put it simply, it is payor dependent for which one you report. Remember when I said insurance verification is important, wink, wink? Medicare requires HCPCS G2212, while other non-Medicare payors may require CPT® 99417. Regardless of which code is required by payor, the gist of it is basically the same; providers may report prolonged service(s) for non-face-to-face and face-to-face time that is spent on a date of service if the time is directly related to patient management. So, for the monitoring of Spravato®, the patient is in the office for 2 hours post-administration, but is the provider only performing work directly related to that patient for the full 2 hours? Most likely the answer to that is no, because while the patient may be in the office for 2 hours, the provider is probably performing other administrative tasks, seeing other patients, etc., not directly related to the care of the Spravato® patient. Time spent obtaining the patient’s vitals at regular increments can be used towards the E/M service, discussed in part 1, but the provider would have to be the one to physically obtain the vitals and do the monitoring to use that time towards the E/M or prolonged service codes. Plus, the real downfall here may be that G2212 and 99417 may only be reported in addition to high complexity E/M services, 99205 or 99215, and only if based on time. So, looking back at the administration code(s), if you are billing anything other than 99205 or 99215, or billing the E/M based on MDM, you automatically cannot bill for provider prolonged service(s).
Ok, provider prolonged service(s) may be out, but you still have prolonged clinical staff services, 99415 and 99416, right? Maybe, maybe not. Again, we must meet the code requirements, which state the clinical staff must be providing direct patient contact extending 30 minutes or more beyond the highest time in the range of total time of the service. Consider the definition of direct patient contact, time spent face-to-face with the patient, to determine if the clinical staff time is applicable in your situation. If the patient is in the office suite, only the time spent when the clinical staff member is in direct contact with the patient may be counted towards prolonged staff service(s). Any time spent away from the patient, where clinical staff are performing other tasks, that time does not count. So periodically checking on the patient, obtaining vitals, does count, however, as soon as that clinical staff member steps away, the clock stops ticking.
In summary, it is imperative your office establish a workflow prior to rendering Spravato® services. All staff members should be aware of the process to ensure quality patient care and compliant billing practices. It all boils down to three things, patient benefits/payor rules, place of service, and provider/staff involvement in rendering the service. There will inevitably always be some variation, but with a standard process in place, you and your staff will be able to easily adjust as needed. And if you need additional help, The Rybar Group is here to support you!
For additional information and resources, please visit:
https://www.spravatohcp.com/payer-coverage-and-reimbursement