2025 Dermatology Coding Updates

ICD-10 updates issued by the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics, took effect this past October 1. This year includes 252 new codes, 36 deletions, and 13 revisions. While most updates have limited impact on dermatology, the following are of particular relevance:

ICD-10 Updates:

Pruritus:

• Previous Code: L29.8 ("Other pruritus").

• New Code: L29.89 ("Other specified pruritus"), offering greater specificity.

Scarring Alopecia:

• L66.1 has been subdivided into:

  • L66.11: Classic lichen planopilaris (including follicular variants).

  • L66.12: Frontal fibrosing alopecia.

  • L66.19: Other lichen planopilaris, including Graham-Little syndrome.

• L66.81: Now specifies central centrifugal cicatricial alopecia, providing a more precise category previously under “Other cicatricial alopecia.”

Social Determinants of Health:

• New Codes:

  • Z59.71: Insufficient health insurance coverage.

  • Z59.72: Insufficient welfare support.

• These additions highlight the growing recognition of socioeconomic factors in patient care. They can also assist in meeting the documentation requirements for Medical Decision-Making (MDM) within CPT coding.

CPT Updates

Important – please refer to the Questions & Answers section after the update summary to learn more about CMS’ stance on these new telehealth codes.

CPT updates effective January 1, 2025 introduce new codes and eliminate the need for telehealth-specific modifiers. Below are key highlights:

Telehealth Services:

• New Code Range: 98000–98016.

• Scope: Covers synchronous (real-time) interactions, including both audio-visual and audio-only services.

• Exclusions: Routine communications related to prior encounters (e.g., sharing biopsy/lab results) are not billable.

• Aggregating Time:

  • Telehealth and in-person service times on the same day can be aggregated for billing purposes. However, overlapping time is counted only once.

    • Example: A patient interaction starts as a telehealth call and concludes with an in-person visit. The total time spent can determine the appropriate billing level.

Telephone Services:

• New Code Range: 98008–98015.

  • These mirror the structure of in-person E/M codes.

  • A minimum of 10 minutes is required to bill.

  • Example Scenario:

    • A physician follows up with a patient via telephone two weeks after initiating treatment to assess progress and adjust the care plan. This qualifies as a billable encounter.

  • Code 98016:

    • Specifically for new problems identified during patient-initiated calls, unrelated to prior encounters within the preceding seven days.

    • If the call results in an in-person visit within 24 hours, the time spent on the call can be added to the in-person service time.

Key Clarifications:

• The dedicated telehealth codes eliminate the need for prior location and modifier identifiers.

• Time stratification for telehealth codes aligns with existing in-person visit codes, making the transition straightforward.

• Non-interactive services (e.g., store-and-forward consultations) retain their existing codes and criteria.

Questions and Answers
(re: 2025 Coding Updates for Dermatology)

Is it true that CMS is not recognizing most of the new Telehealth codes?

The Centers for Medicare & Medicaid Services (CMS) have finalized the Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS), introducing significant changes to telehealth service reimbursements.

Medicare's Non-Recognition of New Telehealth Codes:

CMS acknowledges the American Medical Association's (AMA) introduction of 17 new telehealth-specific Current Procedural Terminology (CPT) codes (98000–98016) for 2025. However, CMS has decided not to recognize 16 of these codes (98000–98015) for Medicare reimbursement, assigning them an "I" (Invalid) status. Medicare will only provide separate payment for CPT code 98016, which pertains to brief virtual check-ins, replacing the previous HCPCS code G2012.

Implications for Healthcare Providers:

• Continued Use of Existing E/M Codes: For telehealth services, Medicare will continue to reimburse providers using existing Evaluation and Management (E/M) codes (e.g., 99202–99215) rather than the new telehealth-specific codes.

• Deletion of Previous Telephone E/M Codes: The previous audio-only telephone E/M service codes (99441–99443) are deleted for 2025. Providers should use the appropriate existing E/M codes for telehealth services.

Private Insurers' Adoption of New Telehealth Codes:

As of December 20, 2024, there is limited information regarding private insurers' adoption of the new telehealth CPT codes (98000–98016). Many insurers are expected to release their 2025 coverage guidelines in the coming weeks. Healthcare providers are advised to consult directly with individual insurers to determine the appropriate coding and reimbursement policies for telehealth services in the upcoming year.

How exactly does the change of L29.8 to L29.89 add greater specificity? It appears that it now simply has a fifth digit?

The update to L29.89 ("Other specified pruritus") from L29.8 ("Other pruritus") is primarily about enhancing documentation and coding accuracy rather than altering the general meaning of the code itself. Here’s why L29.89 provides greater specificity:

1.     Encourages More Detailed Documentation: The addition of the fifth digit aligns with ICD-10-CM's goal to capture as much clinical detail as possible. It prompts healthcare providers to specify the type of pruritus more explicitly in their documentation, distinguishing it from broader or unspecified categories.

2.     Separates 'Other' from 'Unspecified' Codes: The new structure emphasizes the difference between pruritus conditions that are "other specified" (L29.89) versus "unspecified" (L29.9). This distinction helps clarify whether a specific type of pruritus has been documented but does not fall under the primary pruritus codes (e.g., L29.0 for pruritus ani, L29.1 for pruritus vulvae) or if the clinician didn’t document sufficient detail.

3.     Better Reporting and Research: Over time, having a more granular code allows for improved tracking, research, and analysis of specific subcategories of pruritus. For example, cases coded as L29.89 could help identify trends related to specific underlying causes of pruritus that might not warrant their own unique code yet.

4.     Compliance and Reimbursement: Payers may now expect L29.89 to be used when documentation supports "other specified" types of pruritus. Using the correct, more specific code reduces the risk of claim denials or audits for insufficient coding.

In practice, the change does not necessarily require different clinical documentation compared to L29.8. However, it sets the stage for better-defined categories and ensures that cases of "other specified pruritus" are appropriately separated from unspecified or general conditions.

Is L66.1 still valid at all? Do the new codes replace it, or are they simply "additional” codes?

As of October 1, 2024, the ICD-10-CM code L66.1 for lichen planopilaris has been rendered non-billable and replaced by more specific codes to enhance diagnostic precision. These new codes are:

• L66.10: Lichen planopilaris, unspecified

• L66.11: Classic lichen planopilaris

• L66.12: Frontal fibrosing alopecia

• L66.19: Other lichen planopilaris

These additions allow for more detailed documentation and coding of lichen planopilaris subtypes. Therefore, L66.1 is no longer valid for billing purposes, and the new codes should be used to accurately represent the specific diagnosis.

Can you provide "real-world" examples of why and how the "Social Determinants of Health" codes would be used in dermatology?

The introduction of ICD-10-CM codes Z59.71 and Z59.72 enables dermatology clinics to document specific social determinants of health (SDOH) that may influence patient care. Here are real-world examples illustrating their application:

Z59.71 – Insufficient Health Insurance Coverage

Example 1: Delayed Treatment for Suspicious Skin Lesion

A patient presents with a lesion that has recently changed in size and color, raising concerns about melanoma. The patient admits to postponing the dermatology visit due to inadequate health insurance, fearing high out-of-pocket costs. In this case, the dermatologist would document the primary diagnosis related to the skin lesion and add Z59.71 to indicate that insufficient health insurance coverage contributed to the delay in seeking care.

Example 2: Inability to Afford Biologic Therapy for Psoriasis

A patient with moderate to severe psoriasis could benefit from biologic therapy. However, their health insurance plan does not cover biologics, and the patient cannot afford the treatment independently. The dermatologist notes that the lack of adequate insurance coverage limits the patient's treatment options. Here, Z59.71 would be used alongside the primary psoriasis diagnosis to document the impact of insufficient health insurance on treatment decisions.

Z59.72 – Insufficient Welfare Support

Example 1: Limited Access to Wound Care Supplies for Chronic Ulcers

A patient with venous leg ulcers requires regular dressing changes and compression therapy. Due to insufficient welfare support, they cannot afford the necessary wound care supplies, leading to prolonged healing times. The dermatologist would document the primary diagnosis related to the ulcers and add Z59.72 to highlight that inadequate welfare support is affecting the patient's ability to adhere to the recommended treatment plan.

Example 2: Unmet Transportation Needs Hindering Follow-Up Appointments

A patient undergoing treatment for severe eczema misses follow-up appointments because they lack access to reliable transportation and do not receive sufficient welfare support to cover travel expenses. The dermatologist notes that this barrier is impacting the continuity of care. In this scenario, Z59.72 would be used in conjunction with the primary eczema diagnosis to document the social factor affecting the patient's treatment adherence.

By utilizing these specific codes, dermatology clinics can accurately capture the socioeconomic factors influencing a patient's health. This detailed documentation facilitates comprehensive care planning, enables better resource allocation, and supports initiatives aimed at addressing social determinants of health.

How exactly can the SDOH codes assist providers in meeting the documentation requirements for Medical Decision-Making?

Incorporating Social Determinants of Health (SDOH) into patient documentation can significantly influence the level of service coded during Evaluation and Management (E/M) visits. To illustrate this, let's compare two dermatology visits with similar clinical scenarios but differing in the inclusion of SDOH factors.

Scenario Overview:

• Chief Complaint: Both patients present with moderate plaque psoriasis requiring management.

• Clinical Findings: Similar severity and extent of lesions in both cases.

Visit 1: Without SDOH Consideration

• Assessment and Plan:

  • Diagnosis of moderate plaque psoriasis.

  • Prescription for a mid-potency topical corticosteroid.

  • Standard follow-up in 4 weeks.

• Medical Decision Making (MDM):

  • Number and Complexity of Problems Addressed: One chronic condition with exacerbation.

  • Data Reviewed: None beyond history and physical examination.

  • Risk of Complications and/or Morbidity or Mortality: Low, due to standard treatment without complicating factors.

• E/M Code: Based on the above, this visit may qualify for a Level 3 E/M code (e.g., 99213 for an established patient), indicating low complexity in MDM.

Visit 2: With SDOH Consideration

• Additional Information:

  • Patient reports financial instability, impacting the ability to afford medications.

  • Lives in a communal shelter with limited privacy, affecting adherence to treatment regimens.

• Assessment and Plan:

  • Diagnosis of moderate plaque psoriasis.

  • Discussion of cost-effective treatment alternatives, such as generic medications.

  • Coordination with social services to assist with medication access.

  • Customized follow-up plan considering living situation, including potential for telehealth check-ins.

• Medical Decision Making (MDM):

  • Number and Complexity of Problems Addressed: One chronic condition with exacerbation, complicated by socioeconomic factors.

  • Data Reviewed: Additional coordination with social services and consideration of external resources.

  • Risk of Complications and/or Morbidity or Mortality: Moderate, due to treatment limitations imposed by financial and living circumstances.

• E/M Code: The inclusion of SDOH factors elevates the complexity of MDM to moderate. This supports a Level 4 E/M code (e.g., 99214 for an established patient), reflecting the increased effort in managing the patient's condition within the context of their social environment.

Key Takeaways:

• Impact of SDOH on MDM: Documenting SDOH factors such as financial instability (e.g., ICD-10-CM code Z59.6) and inadequate housing (e.g., Z59.1) provides a comprehensive view of the patient's challenges, directly influencing the complexity of medical decision-making.

• Coding Implications: Accurate documentation of SDOH can justify higher-level E/M codes by demonstrating the additional considerations and coordination required to manage the patient's health effectively.

• Clinical Relevance: Addressing SDOH is essential for developing realistic and effective treatment plans, ultimately improving patient outcomes.

Please define what is meant by “welfare support”?

"Welfare support" refers to government-provided assistance aimed at ensuring individuals and families can meet their basic needs and maintain a minimum standard of living. This support encompasses various programs and services, including:

• Financial Assistance: Direct monetary aid to individuals or families with low or no income, such as Temporary Assistance for Needy Families (TANF) in the United States.

• Healthcare Services: Access to medical care through programs like Medicaid, which offers health coverage to eligible low-income individuals.

• Food Assistance: Programs that provide food or financial resources to purchase food, such as the Supplemental Nutrition Assistance Program (SNAP).

• Housing Support: Assistance with securing affordable housing or subsidies to reduce housing costs.

• Unemployment Benefits: Financial support for individuals who are unemployed and seeking work.

• Child Care Assistance: Support to help families afford child care services, enabling parents to work or attend education and training programs.

The “social determinants of health” codes seem to be focused on providing data for government statistics, but can they truly improve patient outcomes?

Incorporating ICD-10-CM Z codes that capture Social Determinants of Health (SDOH) into clinical practice can significantly enhance patient care at the doctor-patient level. Here's how these codes can make a tangible difference:

1.     Personalized Care Planning: By documenting specific SDOH factors—such as insufficient health insurance (Z59.71) or inadequate welfare support (Z59.72)—clinicians gain a comprehensive understanding of the challenges a patient faces. This awareness enables the development of tailored treatment plans that consider these barriers, leading to more effective and realistic care strategies.

2.     Improved Care Coordination: Recording SDOH codes facilitates better communication among healthcare providers and care teams. When all members are informed about a patient's socioeconomic challenges, they can collaborate more effectively to address these issues, ensuring that interventions are cohesive and supportive of the patient's overall well-being.

3.     Enhanced Resource Allocation: Identifying and coding SDOH factors allow healthcare providers to connect patients with appropriate community resources and support services. For instance, a patient documented with Z59.72 (insufficient welfare support) can be referred to social services that provide financial assistance, housing support, or access to affordable medications, directly addressing the patient's needs.

4.     Informed Clinical Decision-Making: Understanding a patient's social context through SDOH codes can influence clinical decisions. For example, if a patient cannot afford certain medications due to insufficient insurance coverage (Z59.71), a physician might prescribe a more affordable alternative or seek assistance programs, ensuring adherence to treatment and better health outcomes.

5.     Proactive Identification of Health Risks: SDOH codes help in identifying patients at higher risk for adverse health outcomes due to their social circumstances. This proactive identification enables early interventions, such as providing additional support or monitoring, to prevent the escalation of health issues.

6.     Support for Value-Based Care Models: In value-based care settings, addressing SDOH is crucial for improving patient outcomes and reducing healthcare costs. Utilizing these codes allows providers to document the complexity of a patient's situation, which can be factored into care management and reimbursement models, ultimately supporting the delivery of comprehensive and equitable care.

While SDOH codes do contribute to broader data collection and health statistics, their application at the individual patient level is instrumental in delivering holistic care. By acknowledging and addressing the social factors that influence health, clinicians can improve patient engagement, adherence to treatment plans, and overall health outcomes.

Can you provide a detailed breakdown of the new “Telehealth Services” codes (for the insurers who will recognize them)?

The introduction of the CPT code range 98000–98016 in 2025 represents a significant update in the coding of telehealth services. Here's a detailed breakdown:

Breakdown of Codes 98000–98016:

• 98000–98003: Synchronous audio-video evaluation and management (E/M) services for new patients, varying by complexity and time.

• 98004–98007: Synchronous audio-video E/M services for established patients, varying by complexity and time.

• 98008–98011: Synchronous audio-only E/M services for new patients, varying by complexity and time.

• 98012–98015: Synchronous audio-only E/M services for established patients, varying by complexity and time.

• 98016: Brief communication technology-based service (e.g., virtual check-in) by a physician or other qualified healthcare professional who can report E/M services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion.

Previous Telehealth Codes:

Prior to 2025, telehealth services were reported using codes such as:

• 99441–99443: Telephone E/M services provided by a physician to an established patient, parent, or guardian.

• G2012: Brief communication technology-based service (virtual check-in) by a physician or other qualified healthcare professional.

Replacement of Prior Codes:

For insurers who recognize the new codes, 98000–98016 are designed to replace the prior codes:

• 99441–99443: Deleted in 2025, with their functions incorporated into the new 98000 series.

• G2012: Replaced by 98016 for virtual check-ins.

Enhancements Over Previous Codes:

The new codes offer several improvements:

• Granularity: They provide more specific distinctions between audio-video and audio-only services, as well as between new and established patients.

• Alignment with E/M Services: The structure aligns more closely with traditional E/M coding, facilitating consistency in documentation and billing.

• Flexibility: By specifying different modalities and patient types, the codes accommodate a broader range of telehealth scenarios.

Medicare's Stance:

It's important to note that, according to the 2025 Medicare Physician Fee Schedule Final Rule, Medicare will not recognize 16 of the 17 new telehealth CPT codes (98000–98016) for payment in 2025. Specifically, codes 98000–98015 will have an "I" (Invalid) status for Medicare purposes. Medicare will only pay separately for brief virtual check-in encounter CPT code 98016, replacing HCPCS code G2012.

Implications for Providers:

• Medicare Patients: For Medicare beneficiaries, providers should continue using existing E/M codes (e.g., 99202–99215) for telehealth services, except for brief virtual check-ins, which should be reported with 98016.

• Non-Medicare Patients: Commercial payers may adopt the new codes; therefore, providers should verify with each payer to determine the appropriate codes for telehealth services.

What would be an example of how 98016 might be used for a dermatology visit?

CPT code 98016 is designated for brief communication technology-based services, commonly known as "virtual check-ins." This code is applicable when a physician or qualified healthcare professional engages in a brief (5–10 minutes) medical discussion with an established patient via telecommunications technology. The interaction must be patient-initiated and should not originate from a related evaluation and management (E/M) service provided within the previous 7 days, nor lead to an E/M service or procedure within the next 24 hours or soonest available appointment.

MEDICARE (CMS) COVERAGE EXAMPLE:

Scenario: Follow-Up on Actinic Keratosis Treatment

Patient Background:

• A 72-year-old Medicare patient has a history of actinic keratosis (AK), treated with cryotherapy at his visit two weeks ago.

• The patient calls the dermatologist’s office with concerns about persistent redness and slight swelling at one of the treated sites.

Interaction Details:

1.     Patient Initiation:

o    The patient contacts the clinic expressing concerns about the treated lesion.

o    The dermatologist determines that a brief virtual consultation is appropriate to assess the situation.

2.     Virtual Check-In:

o    The dermatologist schedules a 7-minute telephone consultation to discuss the symptoms.

o    The dermatologist reviews the patient’s description and asks clarifying questions about the redness and swelling.

o    Based on the discussion, the dermatologist reassures the patient that the symptoms are within the expected post-treatment range and advises continued application of a prescribed topical emollient.

3.     No Recent or Upcoming E/M Services:

o    The interaction does not stem from another related service within the past 7 days.

o    The issue is resolved during the call, with no need for an in-person visit or additional procedures in the next 24 hours.

Billing Using CPT 98016:

• The dermatologist documents the interaction thoroughly, including:

  • The patient's reported symptoms.

  • The medical advice provided during the call.

  • Confirmation that the service was initiated by the patient.

• CPT code 98016 is billed for this brief virtual check-in.

Requirements Support 98016:

• Brief Medical Discussion: The interaction is concise, lasting within the 5–10 minute range specified by the code.

• Appropriate Timing: It occurs outside the 7-day window following the initial in-person service and does not lead to another E/M visit within 24 hours.

• Patient-Initiated: The patient reached out to address a concern, meeting the key requirement for using CPT 98016.

PRIVATE INSURER (NON-MEDICARE) EXAMPLE IN DERMATOLOGY:

Scenario: An established patient undergoing treatment for acne has concerns about a new skin reaction after starting a prescribed topical medication.

Application of 98016:

1.     Patient Initiation: The patient contacts the dermatology clinic expressing concerns about redness and irritation after using the new topical treatment.

2.     Brief Medical Discussion: The dermatologist schedules a virtual check-in, conducted via telephone, to discuss the patient's symptoms. During this 7-minute conversation, the dermatologist assesses the reaction, provides reassurance, and offers guidance on adjusting the medication application to alleviate the irritation.

3.     No Related Recent or Upcoming E/M Services: This interaction is independent, not stemming from a related E/M service provided within the past 7 days, and does not result in scheduling an in-person visit within the next 24 hours or the soonest available appointment.

In this scenario, the dermatologist would report CPT code 98016 for the virtual check-in, as it meets the criteria of a brief communication technology-based service with an established patient.

Have any private insurers disclosed their position with respect to the updated Telehealth codes?

As of December 20, 2024, information regarding the adoption and reimbursement of the new CPT codes 98000–98016 for telehealth services by major private insurers is limited. Here's a summary of the current positions for each insurer:

1. UnitedHealth Group

• Position Statement: No specific statements have been found regarding the adoption of CPT codes 98000–98016.

2. Anthem, Inc. (Elevance Health)

• Position Statement: Anthem has updated its Virtual Visits reimbursement policy, effective September 1, 2024, outlining guidelines for telehealth services.  

3. Aetna (CVS Health)

• Position Statement: Aetna has not publicly specified its stance on the new telehealth CPT codes 98000–98016.

4. Cigna

• Position Statement: No specific statements have been found regarding the adoption of CPT codes 98000–98016.

5. Humana

• Position Statement: Humana has provided a telehealth reference guide for healthcare providers, offering information on coverage, reimbursement rules, and requirements for telehealth services.  

6. Blue Cross Blue Shield Association (BCBSA)

• Position Statement: The BCBSA has not issued a unified position on the new telehealth CPT codes 98000–98016. Individual state plans may have their own policies.

7. Kaiser Permanente

• Position Statement: No specific statements have been found regarding the adoption of CPT codes 98000–98016.

8. Centene Corporation

• Position Statement: No specific statements have been found regarding the adoption of CPT codes 98000–98016.

9. Molina Healthcare

• Position Statement: No specific statements have been found regarding the adoption of CPT codes 98000–98016.

10. WellCare (Centene)

• Position Statement: No specific statements have been found regarding the adoption of CPT codes 98000–98016.

Given the evolving nature of telehealth services and coding updates, it is advisable for healthcare providers to maintain direct communication with each insurer to receive the most accurate and up-to-date information regarding telehealth service coverage and reimbursement.