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Proposed 2023 physician pay schedule deepens Medicare’s instability

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Proposed 2023 physician pay schedule deepens Medicare’s instability

The Medical Association is working with the AMA and many national specialty societies to analyze and comment on CMS proposed 2023 fee schedule. The following article was prepared by the AMA and outlines efforts to address problems that have been identified with the proposed fee schedule:

After a thorough analysis, the AMA has weighed in with detailed comments (PDF) on the Centers for Medicare & Medicaid Services’ (CMS) proposed policies for the 2023 Medicare physician payment schedule.

The proposed 2023 Medicare physician payment schedule (PDF) shows the agency must work with Congress to avert budget-neutrality cuts and implement an inflationary update for doctors who now are in line to see a 4.42% pay cut in January.

“The AMA is deeply alarmed about the growing financial instability of the Medicare physician payment system due to a confluence of fiscal uncertainties physician practices face related to the ongoing pandemic, statutory payment cuts, lack of inflationary updates, and significant administrative barriers,” says the AMA’s comment letter to CMS.

“The payment system is on an unsustainable path that is jeopardizing patient access to physicians. The resulting discrepancy between what it costs to run a physician practice and actual payment, combined with the administrative and financial burden of participating in Medicare, is incentivizing market consolidation,” the letter adds.

The AMA is asking Congress to:

  • Extend the congressionally enacted 3% temporary increase in the Medicare fee schedule.
  • Provide relief for an additional 1.5% budget-neutrality cut that is planned for 2023.
  • End the statutory annual freeze and provide an inflation-based update for the coming year.
  • Waive the 4% pay-as-you-go sequester necessitated by passage of legislation unrelated to Medicare.

In addition, physicians are urging CMS to work with Congress to extend the 5% incentive payment physicians can earn for participating in an Advanced Alternative Payment Model. Congress also needs to extend the $500 million in funding for the “exceptional performance” payments that physicians can earn under the Merit-based Incentive Payment System (MIPS).

Earning theses bonuses in 2022 will affect payment adjustments in 2024. The CMS proposal does not include estimates for these incentives and bonuses in 2023 as they are set to expire under current law.

The lapse of these incentives, coupled with the 4.42% pay cut, threatens patient access to Medicare-participating doctors and undermines the sustainability of physician practices. The AMA is strongly advocating that Congress avert the significant conversion-factor cut. Instead, Congress should extend the 3% increase that is set by law to expire at the end of this year, prevent the additional 1.5% budget neutrality cut for 2023, and provide a positive update to account for inflation as measured by the Medicare Economic Index (MEI).

In nearly 100 pages of detailed comments, the AMA sets out its response to CMS proposed rule. Here are some key steps the AMA is advising CMS to take as it assembles the final version of the 2023 Medicare physician payment schedule.

The agency should:

Continue its current coverage and payment policies for telephone visits and audio-visual telehealth services until the joint Current Procedural Terminology®-RVS Update Committee (RUC) Telemedicine Office Visits Workgroup determines accurate coding and valuation, as needed, for office visits performed via audiovisual and audio-only modalities.

Pause consideration of other sources of cost data for use in the MEI until the AMA’s extensive effort to collect practice-cost data from physician practices is complete.

Apply the office E/M visit increases to the office visits, hospital visits and discharge-day management visits included in surgical global payment, as it has done historically.

Conduct a demonstration to determine the financial and operational efficiencies for Medicare patients with underlying medical conditions who require integral dental services as a condition of their covered, primary Medicare Part A service.

Separate the funding source to cover dental services from—and have no impact on—the Medicare physician payment schedule. 

Adopt the RUC’s recommended work relative value units and direct practice-expense inputs for vaccine administration services. The AMA supports CMS’ proposal to annually update the payment amount for administration of Part B preventive vaccines to account for changes in the cost of administering those vaccines.

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CMS Issues COVID-19 Health Care Staff Vaccination Interim Final Rule

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CMS Issues COVID-19 Health Care Staff Vaccination Interim Final Rule

by Lindsey Phillips, Burr & Forman, LLP

On November 4, 2021, the Centers for Medicare & Medicaid Services (“CMS”) announced its interim final rule regarding vaccination requirements for eligible staff of certain healthcare providers. The rule, which becomes effective on November 5, 2021, is expected to apply to approximately 76,000 healthcare providers and cover over 17 million healthcare workers across the United States.

What Are the New Requirements?

The Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule (“IFC”) contains three primary requirements for covered providers:

  1. A plan for fully vaccinating all eligible staff.
  2. A plan for providing exemptions and accommodations for those who are exempt from vaccinations.
  3. A plan for tracking and documenting staff vaccinations.

Who Is Covered by the Requirements?

The vaccination requirements apply to eligible staff of Medicare and Medicaid-certified healthcare providers and supplier types that are subject to CMS’s health and safety regulations, which are commonly known as Conditions of Participation (CoPs), Conditions for Coverage (CfCs), or Requirements of Participation. Covered providers include:

  • Ambulatory Surgery Centers
  • Clinics
  • Community Mental Health Centers
  • Comprehensive Outpatient Rehabilitation Facilities
  • Critical Access Hospitals
  • End-Stage Renal Disease Facilities
  • Home Health Agencies
  • Home Infusion Therapy Suppliers
  • Hospices
  • Hospitals
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities
  • Long-Term Care Facilities
  • Programs for All-Inclusive Care for the Elderly Organizations (PACE)
  • Psychiatric Residential Treatment Facilities (PRTFs)
  • Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
  • Rural Health Clinics/Federally Qualified Health Centers
  • Rehabilitation Agencies

Of note, the requirements do not apply to Assisted Living Facilities, Group Homes, Home and Community-based Services, or physician’s offices. Additionally, Religious Nonmedical Health Care Institutions (RNHCIs), Organ Procurement Organizations (OPOs), and Portable X-Ray Suppliers are excluded. 

Please note that while physician’s offices are not covered by this mandate, physicians who practice at facilities that are covered by the mandate may be impacted. For example, while an anesthesiology private physician practice may not be subject to the mandate, the hospital where the anesthesiologist is on medical staff and provides certain services is subject to the mandate. As a provider who provides care within the hospital, the anesthesiologist would be subject to the vaccine mandate. 

Who Are Eligible Staff?

The vaccination requirements apply to staff members who provide any care, treatment, or other services for a covered provider or its patients. This includes individuals who provide care, treatment, or other services for the covered provider or its patients under contract or other similar arrangements. Examples of eligible staff include, but are not necessarily limited to:

  • Employees
  • Licensed practitioners
  • Students
  • Trainees
  • Volunteers

While the vaccination requirements do not apply to full time teleworkers (i.e. those who provide services 100% remotely and have no contact whatsoever with patients and other staff members), the requirements do apply to staff who work offsite and have contact with patients or other staff, such as home health providers. Additionally, the requirements apply to physicians admitting or treating patients in-person within a covered provider. For example, a physician who enters a long-term care facility or hospital to treat patients would need to be vaccinated.

What Exactly Does the New Rule Require? 

Plan for Vaccination

Covered providers must implement a plan for full vaccination of their eligible staff by December 5, 2021. Phase 1 requires that all eligible staff of covered providers have the first dose of a primary series or a single dose COVID-19 vaccine by December 5, 2021. Phase 2 requires that all eligible staff of covered providers complete the primary vaccination series by January 4, 2022. The completion of a primary vaccination series is defined as the administration of a single-dose vaccine (such as the Johnson & Johnson COVID-19 vaccine) or the administration of all required doses of a multi-dose vaccine (such as the Pfizer-BioNTech COVID-19 vaccine or the Moderna COVID-19 vaccine). Although additional doses of the vaccine are currently recommended to some individuals, the IFC does not require that staff receive booster doses to be fully vaccinated.

Plan for Providing Exemptions and Accommodations 

Because CMS has acknowledged that there may be limited circumstances when exemptions to the vaccination requirements are appropriate, covered providers must also implement a plan that establishes exceptions to the vaccine requirements. As a reasonable accommodation under the Americans with Disabilities Act (ADA), CMS requires covered providers to allow exemptions for eligible staff members who have medical conditions for which vaccines are contraindicated. Covered providers have the flexibility to establish their own processes that permit eligible staff to request medical exemptions. Any medical exemption must be signed and dated by a licensed practitioner. The documentation must also include information that specifies which of the authorized COVID-19 vaccines are clinically contraindicated and the recognized clinical reasons for the contraindications.

CMS also requires covered providers to allow exemptions for religious beliefs, observances, and practices, as part of the requirements of Title VII of the Civil Rights Act of 1964. Similar to medical exemptions, covered providers have the flexibility to establish their own processes that permit staff to request religious exemptions. Covered providers are encouraged to review the Equal Employment Opportunity Commission’s Compliance Manual on Religious Discrimination when determining whether an individual’s request for a religious exemption is valid. 

Plan for Documentation

As part of the IFC, covered providers must also implement a plan for tracking and documenting staff vaccinations. The IFC does not, however, establish any new data reporting requirements. Hospitals and long-term care facilities are expected to continue complying with their current facility-specific data reporting requirements.

How Will CMS Enforce the IFC?

CMS has stated that it will work with State Survey Agencies to regularly review compliance with the IFC. State survey agencies will assess all covered providers for compliance with the requirements during standard recertification surveys and will also assess for compliance during complaint surveys. 

How Does the IFC Interact with Other Rules?

On November 4, 2021, the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) announced its COVID-19 Vaccination and Testing Emergency Temporary Standard (ETS), which applies to employers with 100 or more employees. To the extent that the IFC contradicts any other rule, covered providers should look to the IFC first. In other words, if a healthcare provider participates in and is certified under the Medicare and Medicaid programs and is regulated by Conditions of Participation, Conditions for Coverage, or Requirements for Participation, then the covered provider must abide by the requirements set forth in the CMS Omnibus Staff Vaccination Rule. Similarly, this rule pre-empts any state law to the contrary.

The IFC is open for comment until January 4, 2022. All stakeholders are encouraged to submit feedback. 

For more information, please contact Lindsey Phillips at lphillips@burr.com or at (205) 458-5370. 

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Telehealth in Alabama during COVID-19 Public Health Emergency (PHE)

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Telehealth in Alabama during COVID-19 Public Health Emergency (PHE)

prepared by Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC

March 19, 2020

The most important thing to remember is that payers have differing definitions of what they consider telehealth.  I recommend checking with the applicable insurer for the most up-to-date information affecting requirements for coding and billing of telehealth services.  A few things to ask about: 

  • What are the effective dates?  Most insurers are limiting this exemption to a specific period of time. 
  • What services are covered? 
  • How are those to be billed? 
  • Do we use telehealth codes or office visit codes? 
  • What place of service? 
  • What modifiers are necessary?
  • For fee-for-service, traditional Medicare

The information below pertains to the major payers in Alabama as of 3/18/2020 –

Blue Cross Blue Shield of Alabama is allowing providers to bill for phone call treatment of existing patients under the established patient office visit codes from 3/16/2020 – 4/16/2020.  They are allowing codes up to 99213 with place of service code 02 (zero two) for telehealth. No modifier is required.  Many providers are concerned about reaching that level of service when no examination can be performed.  Remember that established patient office visits require only two of the three key components – history, examination, medical decision-making.  If the physician documents an expanded problem-focused history and low complexity medical decision-making, 99213 will be supported.  This must be the physician speaking with the patient, not the office staff.

Alabama Medicaid normally requires separate credentialing for providers performing telehealth; however, that restriction has been waived 3/16/2020 – 4/16/2020 (dates of service).   Medical providers may bill established-patient evaluation and management codes 99211, 99212 and 99213 for telephone consultations.   Psychologists and behavioral health professionals should bill 90832, 90834, 90837, 90846, 90847 and H2011. A dental provider should bill D0140.  Place of service code 02 (zero two) for telehealth and modifier CR are required.  Verbal consent must be obtained and documented in the medical record.  These visits will count against the patient’s office visit limit of 14 visits per year.

United Health Care is waiving originating site restrictions for their commercial, Medicare Advantage, and Medicaid plans.  The patient may be at home or at another location.  All the other requirements for telehealth must be met – real-time audio and video communication system required. These include the place of service 02 and the GQ (asynchronous telecommunications system) or GT (interactive audio and video telecommunication system) modifier.  This waiver is only in effect until April 30, 2020.

Medicare

Fee-For-Service Medicare DOES NOT allow telephone calls to be billed as telehealth.  The PHE waiver provides three specific exceptions to the existing telehealth regulations:

  1. the patient can be in their home or other location – they do not have to be in a healthcare facility in a HPSA.
  2. the audio-video link can be something as simple as Skype or FaceTime or Facebook Messenger video calls – but it has to be a real-time audio AND video one-to-one connection, not something public-facing
  3. costshare can be waived – it is not automatically, but it can be waived at the providers’ discretion.

CMS also stated that they will not audit to verify that there is an established patient relationship.  Services are limited to the list of telehealth services at:  https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

This does include office visits, consultations, Transitional Care Management, and Annual Wellness Visits.  Place of service is 02 (zero two) for telehealth.  No modifier is necessary unless you are billing from a CAH Method II hospital (GT) or you are treating the patient for an acute stroke (G0).  There is also a modifier for a telemedicine demonstration project in Alaska or Hawaii (GQ).

NOTE: Although CMS stated that no modifier is necessary, Palmetto GBA is requesting modifier CR be appended for tracking purposes.

For services that have a site of service differential, payment will be made at the facility rate.

CMS has not specified an end date for these exceptions, just that they will be allowed as long as the Public Health Emergency declaration is in effect.

If there is not a real-time audio-video connection, then you are limited to one of the following:

Virtual Check-In

  • G2012 – Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management 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
  • G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, 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

Please note the following restrictions:

  • Established patients only (same definition as for other E&M services)
  • Verbal consent required and must be documented in the patient’s medical record
  • No service-specific documentation requirements but medical necessity must be documented.
  • May only be billed by those providers who can perform and bill E&M services

To clarify – G2012 has been in effect since 1/1/2019 – it is supposed to be for an established patient, but CMS has said they will not audit for that requirement during this time.  It does not require the video link, so it is really the only option for phone calls.  It cannot be related to an office visit within the past 7 days, as that would be considered part of the work of the already-billed office visit.  And if the doctor tells the patient to come in at the first available appointment, it can’t be billed as it would be considered the pre-work for the upcoming office visit.  As it specifies 5-10 minutes of medical discussion, time should be documented.

For email or portal communication, we also have these codes, new for 2020:

  • #99421 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • #99422 – …11-20 minutes
  • #99423 – … 21 or more minutes

Please note the following restrictions:

  • Patient-initiated digital communications requiring a clinical decision that would otherwise be made during an office visit
  • Physician/Qualified Healthcare Professional (QHP) time only
  • Not billable if patient seen in person or through telehealth within 7 day period

For All Payers –

There have been questions on how to perform a visit by phone or audio-video without being able to examine the patient.  First of all, established patient visits require two of the three key components:  history, examination, and medical decision-making.  A visit can be billed based on history and medical decision-making.  However, some examination can be done without laying hands on the patient.  Observation can be done through video, and sometimes just through audio.  A physician can observe skin tone, abnormal movements, respiratory effort and many other exam elements without being able to necessarily touch the patient.  A complete Psychiatric exam can be accomplished through talking with the patient.

For example, the patient calls in with complaint of dysuria. The physician documents the complaint (Duration, Timing) and further asks questions about fever, nausea and vomiting (Constitutional and Gastrointestinal Review of Systems).  He also reviews the patient’s Past Medical History and Allergies.   Based on her previous history, he suspects that the patient has a urinary tract infection and orders an antibiotic.

A patient with asthma calls in with an exacerbation – the physician can actually hear the patient wheezing over the telephone – that would be documented as a problem-focused examination.

The key point is that the physician himself must have the conversation with the patient on the phone or through the audio-video link.  This may be something that a nurse may have handled previously, but now it must be performed by the physician to be billable. 

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Appropriate Use Criteria for Advanced Diagnostic Imaging

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Appropriate Use Criteria for Advanced Diagnostic Imaging

Contributed by: Gregg Everett, Gilpin Givhan

The Protecting Access to Medicare Act (PAMA) was passed in 2014.  PAMA required the Centers for Medicare and Medicaid Services (CMS) to establish a program that promotes “Appropriate Use Criteria” (AUC) for advanced diagnostic imaging. AUC’s are evidence-based criteria that assist professionals who order and furnish certain imaging services to make the most appropriate treatment decisions for specific clinical conditions. Once the AUC program is fully implemented (2021), payment will only be made for an advanced diagnostic imaging service if the Medicare claim indicates that the ordering professional consulted with a qualified Clinical Decision Support Mechanism (CDSM) about whether the ordered service meets an applicable AUC.  A CDSM is an interactive electronic tool for use by clinicians that communicates AUC information and assists in making appropriate treatment decisions during a patient’s workup.  An ordering professional is a physician or other licensed professional who orders an imaging service.  The settings covered include hospital outpatient departments (which includes the hospital’s ER), ambulatory surgery centers, physicians’ offices and IDTF’s.  

Advanced diagnostic imaging services include MRI’s, CT scans, PET scans and nuclear medicine. The CDSM must be reported on claims for payment using G-codes, modifiers and, eventually, the ordering physician’s NPI. For the period July 1, 2019, through December 31, 2019, only voluntary reporting was required.  Beginning January 1, 2020, an educational and operations testing period will be implemented, which is expected to run through December 31, 2020. For now, CMS will still pay a claim, whether or not the claim correctly includes AUC information. Eventually, CMS must develop outlier criteria (which will require some ordering professionals to obtain prior authorizations) and will not pay those claims that do not have AUC information, unless a specific exception is met. The exceptions include emergency services provided to individuals with emergency medical conditions (EMTALA definition), inpatient care where payment is made under Part A Medicare, or significant hardships, which includes insufficient internet access and EHR or CDSM vendor issues.  

Qualified CDSM’s (only national professional medical specialty societies or other organizations of providers who predominantly provide direct patient care may develop CDSM’s) must be approved by CMS and must meet other criteria, such as providing a certification or other documentation at the time of the order that a qualified CDSM was consulted, and whether or not the service ordered met the requirements of the specific referenced AUC. The regulations also list certain “priority clinical areas” that will be monitored to identify outlier ordering professionals as follows:  coronary artery disease (suspected or diagnosed), suspected pulmonary embolisms, headache (traumatic and non-traumatic), hip pain, low back pain, shoulder pain (including suspected rotator cuff injury), cancer of the lung (primary or metastasis, and suspected or diagnosed), and cervical and back pain. Ordering physicians and settings for these imaging services should begin the process of including AUC’s on Medicare claims in January 2020.

For more information see:

  1. “Protecting Access to Medicare Act of 2014,” Section 216, (Public Law 113-93), 42 U.S.C. Section 1395m(p) and (q).
  2. 42 CFR Section 414.94 – “Appropriate Use Criteria for Advanced Imaging Services.”
  3. “Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period—Claims Processing Requirements”; MLN Matters Number MM11268 Revised December 6, 2019.
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CMS Releases Physician Fee Schedule Final Rule

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CMS Releases Physician Fee Schedule Final Rule

The Centers for Medicare and Medicaid Services (CMS) released its final rule for the CY 2020 Physician Fee Schedule. The Medical Association and the AMA will continue to review the rule and analyze these policies in the coming weeks. Attached is a summary of some of the policies CMS finalized in the rule.

Some of the highlights of the final rule are:

  1. E/M Coding: Finalizes new E/M coding policy effective January 1, 2021. E/M codes for new patients will be 4 levels (CPT codes 99202-205) and for established patients, there will be 5 levels (CPT Codes 99211-99215)
  2. Conversion factor: $36.09 resulting in a .14% increase in fees
  3. Scope of Practice-Physician Supervision Requirements for Physician Assistants (PAs). CMS finalized its revisions to regulations on physician supervision for physician assistant services. The current policy requires general physician supervision for PA services, however, CMS’ revisions provide that the statutory physician supervision requirement for PA services is met when a PA furnishes their services in accordance with state law and state scope of practice rules for PAs in the state in which the services are furnished.
  4. Physician Enrollment CMS finalized new authority to deny or revoke a physician’s enrollment if he or she has been subject to prior action from a state oversight board, federal or state health care program, Independent Review Organization (IRO) determination(s), or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care with underlying facts reflecting improper physician or other eligible professional conduct that led to patient harm

For a full summary of the physician payment rule, click here.

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E/M Code Changes: A Deeper Dive at What Could be Coming for 2021

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E/M Code Changes: A Deeper Dive at What Could be Coming for 2021

This is the second in a series of articles reviewing notable changes in the 2019 Physician Fee Schedule Final Rule and provides a deeper discussion of the potential changes to the E/M Coding regime scheduled to take effect in 2021. For the original article, please see Evaluating and Managing the E/M Codes for 2019 and Beyond.

Brief Recap

The Centers for Medicare and Medicaid Services proposed some major changes to the way Evaluation and Management services are reimbursed in the 2019 Physician Fee Schedule Proposed Rule. The PFS Final Rule[1] adopted some of the proposed changes but scheduled them to take effect in 2021. The commentary on these proposals and CMS’s responses in the PFS Final Rule provide some valuable insight into what CMS is trying to accomplish with the E/M reimbursement changes and what these changes might ultimately look like when made effective in 2021.

Proposals for 2021

Collapsing Reimbursement for Levels 2-4.  CMS has proposed to collapse the reimbursement for E/M level 2 through level 4[2] codes into a single reimbursement amount for office/outpatient settings. To come up with this combined payment rate, CMS is taking the average of the current inputs for determining E/M reimbursement (work RVUs, direct PE inputs, time, and specialty mix) for level 2 through 4 E/M codes, weighted by the frequency with which each code is currently billed (based on the most recent five years of utilization data). For an example of what this new reimbursement structure might look like, see Table 19 and Table 20 below (excerpted from the Final Rule), which compare the 2021 E/M reimbursement methodology to the current methodology for both new and established patients in terms of 2018 dollars:

As you might expect, this new reimbursement structure will likely result in a reduction in overall reimbursement for many physicians who ordinarily bill higher level E/M codes. Fortunately, CMS is proposing new add-on codes (to be billed only with the combined level 2 through 4 visits) with additional reimbursement which should mitigate some of the effects of the new E/M reimbursement structure.

Add-On Codes.  CMS finalized its proposal for new add-on codes to account for primary care and particularly complex visits, as well as extended visits associated with E/M services. CMS indicated that there should not be any additional documentation requirements for these add-on codes (for the most part)[3] and that information already captured on the claim form should suffice to show that the E/M service provided was for primary care.

Primary Care Add-On Code.  CMS proposed an add-on code (GPC1X) to be appended to claims for primary care E/M services. Notably, the add-on code only applies to face-to-face time with patients[4], and it cannot be appended to a global procedure code that encompasses E/M services. CMS expects this add-on code to be used predominantly by primary care practitioners (e.g., family medicine, internal medicine, pediatrics, and geriatrics), and in fact, indicated that this add-on code would likely be billed for almost all office/outpatient-based E/M services provided by these practitioners. However, CMS also noted that some specialists also function as primary care practitioners (e.g., OB/GYN or cardiologist) and may be able to utilize this add-on code.

Add-On Code for Specialty Professionals with Large E/M Volume.  CMS also proposed an add-on code (GCG0X) for certain specialties which perform mostly high-level (4 or 5) E/M services (rather than procedures) involving “non-procedural approaches to complex conditions that are intrinsically diffuse to multi-organ or neurologic diseases.” CMS originally included certain specialties[5] in the descriptor for this add-on code but has noted that several appropriate specialties[6] were omitted and that the appropriate reporting of this add-on code “should be apparent based on the nature of the clinical issues addressed at the E/M visit, and not limited by the practitioner’s specialty.” CMS also noted that there may be some rare instances where both the primary care add-on code and the specialty professional add-on code could be billed for the same service (provided all the requirements for both codes are met in a single E/M visit).[7]

Extended Visit Add-On Code.  There is also an add-on code (GPRO1) to account for additional resources utilized when physicians have extended visits with patients. This code may be billed if the practitioner spends between 34 and 69 minutes (for established patients) or 38 and 89 minutes (for new patients) of face-to-face time with the patient, regardless of which level (2, 3, or 4) E/M code was reported. Providers will have to note the amount of time spent face-to-face with the patient in order to bill for the extended visit code.

Choice of Documentation Method.  The current (1995 or 1997) E/M documentation guidelines[8] are based on three factors (all of which must be documented): History or Present Illness, Physical Examination, and Medical Decision Making (MDM). Starting in 2021, practitioners will have the option to document E/M services using any one of the following documentation methods: (1) the current (1995 or 1997) guidelines; (2) MDM only; or (3) time only. If practitioners decide to use the existing guidelines or the MDM-only documentation approach, they would only need documentation consistent with the current level 2 E/M service in order to be reimbursed the combined amount for level 2 through 4 E/M services,[9] or consistent with the level 5 documentation requirements where a level 5 E/M code is billed. For practitioners using time as the documentation method, the practitioner must document face-to-face time personally spent with the patient at least equal to the typical time associated with the applicable level of E/M Code.[10]

Regardless of which documentation method practitioners choose, they must still be diligent in documenting medical necessity, as CMS noted several times in the Final Rule that medical necessity would have to be documented in the record regardless of the documentation method the provider chooses. Based on CMS’s comments in the Final Rule, practitioners may expect additional opportunities to comment on the allowable documentation methods in the coming years before the policy is finalized in 2021.

Conclusion

If these proposals move forward over the next several years, it appears there will be substantial disruption not only in how E/M services are reimbursed, but in how they are documented and billed. It is unclear whether these proposals will achieve CMS’s goal of reducing the administrative burden on practitioners, as the proposals simplify E/M coding in some respects and complicate it in others. Either way, practitioners should have the opportunity over the next two years to continue to comment on these proposals in an effort to have CMS modify or refine them before they go into effect in 2021.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

 

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] CMS originally proposed to collapse the reimbursement for E/M level 2 through 5 services into a single reimbursement amount but for now has decided to keep a separate reimbursement amount for level 5 E/M services to “better account for the care and needs of particularly complex patients.”

[3] For instances where the billing of the appropriate add-on code is not as readily apparent based on the information on the claim form, practitioners should consider additional documentation in the medical record to support the billing of the add-on codes.

[4] There are already add-on codes for non-face-to-face time, such as CCM and BHI codes.

[5] Endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/GYN, allergy/immunology, otolaryngology, cardiology, or interventional pain management.

[6] Nephrology, psychiatry, pulmonology, infectious disease, and hospice and palliative care medicine.

[7] CMS provides an example of a cardiologist in a rural area who provides care for complex cardiac conditions as well as primary care in his or her clinical practice. If the cardiologist provided both primary care services and specialty cardiology services in a given E/M visit, both GPC1X and GCG0X could be billed for the visit.

[8] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[9] For example, under the current guidelines, the practitioner must document: (1) a problem-focused history that does not include a review of systems or a past family or social history; (2) a limited examination of the affected body area or organ system; and (3) a straightforward MDM measured by minimal problems, data review, and risk (two of these three). By contrast, a practitioner using the MDM-only method would only have to document straightforward MDM measured by minimal problems, data review and risk (two of these three).

[10] This approach is consistent with the current policy guidelines that time can only be used as the applicable documentation method for E/M codes where counseling and/or coordination of care accounts for more than 50% of the face-to-face time between physician and patient. The typical time associated with a service or procedure is maintained in the AMA CPT codebook.

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CMS Announces New Medicaid Opportunity to Expand Mental Health Treatment Services

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CMS Announces New Medicaid Opportunity to Expand Mental Health Treatment Services

The Centers for Medicare & Medicaid Services recently sent a letter to State Medicaid Directors outlining existing and new opportunities for states to design innovative service delivery systems for adults with serious mental illness and children with serious emotional disturbance. The letter includes a new opportunity for states to receive authority to pay for short-term residential treatment services in an institution for mental disease for these patients. CMS believes these opportunities offer states the flexibility to make significant improvements on access to quality behavioral health care.

Medicaid is the single largest payer of behavioral health services, including mental health and substance use services in the U.S. By one estimate, more than a quarter of adults with a serious mental illness rely on Medicaid. About 10.4 million adults in the U.S. had an SMI in 2016, but only 65 percent received mental health services in that year. Serious mental health conditions can have detrimental impacts on the lives of individuals with SMI or SED and their families and caregivers. Since these conditions often arise in adolescence or early adulthood and often go untreated for many years, individuals with SMI or SED are less likely to finish high school and attain higher education, disrupting education and employment goals.

“More treatment options for serious mental illness are needed, and that includes more inpatient and residential options. As with the SUD waivers, we will strongly emphasize that inpatient treatment is just one part of what needs to be a complete continuum of care, and participating states will be expected to take action to improve community-based mental health care,” said Health and Human Services Secretary Alex Azar. “There are effective methods for treating the seriously mentally ill in the outpatient setting, which have a strong track record of success and which this administration supports. We can support both inpatient and outpatient investments at the same time. Both tools are necessary, and both are too hard to access today.”

CMS currently offers states the flexibility to pursue similar demonstration projects under Section 1115 (a) of the Social Security Act, regarding substance use disorders (SUDs), including opioid use disorder. To date, CMS has approved this authority in 17 states, where it is already improving outcomes for beneficiaries. For example, early results in Virginia show a 39 percent decrease in opioid-related emergency room visits, and a 31 percent decrease in substance-use related ER visits overall after implementation of the demonstration. With this new opportunity, CMS will be able to offer a pathway forward to the 12 states who have already expressed interest in expanding access to community and residential treatment services for the full continuum of mental health and substance use disorders. About a quarter of individuals with SMI have a co-occurring SUD.

States participating in the SMI/SED demonstration opportunity will be expected to commit to taking a number of actions to improve community-based mental health care. These commitments to improving community-based care are linked to a set of goals for the SMI/SED demonstration opportunity and will include actions or milestones to ensure good quality of care in IMDs, to improve connections to community-based care following stays in acute care settings, to ensure a continuum of care is available to address more chronic, on-going mental health care needs of beneficiaries with SMI or SED, to provide a full array of crisis stabilization services, and to engage beneficiaries with SMI or SED in treatment as soon as possible. States are encouraged to build on the opportunities for innovative service delivery reforms discussed in the first part of this letter and summarized below in order to achieve these milestones and goals.

Through this demonstration opportunity, federal Medicaid reimbursement for services will be limited to beneficiaries who are short-term residents in IMDs primarily to receive mental health treatment. CMS will not approve a demonstration project unless the project is expected to be budget neutral to the federal government.

States will also be expected to report information detailing actions taken to achieve the milestones and goals of these demonstrations as well as data and performance measures identified by CMS as key indicators of progress toward meeting the goals of this initiative.

In addition to the 1115 demonstration opportunity the letter also describes strategies under existing authorities to support innovative service delivery systems for adults with SMI and children with SED, that address the following issues:

  • Earlier identification and engagement in treatment, including improved data-sharing between schools, hospitals, primary care, criminal justice, and specialized mental health providers to improve communications;
  • Integration of mental health care and primary care that can help ensure that individuals with SMI or SED are identified earlier and connected with the appropriate treatment sooner;
  • Improved access to services for patients across the continuum of care including crisis stabilization services and support to help transition from acute care back into their communities;
  • Better care coordination and transitions to community-based care; and
  • Increased access to evidence-based services that address social risk factors including services designed to help individuals with SMI or SED maintain a job or stay in school.

CMS announced this new demonstration opportunity following the publication of the Medicaid Managed Care proposed rule. States identified key concerns in the 2016 final rules limitation regarding 15-day length of stay for managed care beneficiaries in an IMD. CMS did not propose any changes to this requirement at this time; however, CMS is asking for comment from states for data that could support a revision to this policy. Meanwhile, this new demonstration opportunity will give interested states the ability to seek federal authority to have greater flexibility to pay for residential treatment services in an IMD as part of broader delivery system improvements.

For more information, please visit: https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf

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Evaluating and Managing the E/M Codes for 2019 and Beyond

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Evaluating and Managing the E/M Codes for 2019 and Beyond

Editor’s Note: This article is the first in a series of articles about notable changes in the 2019 Physician Fee Schedule Final Rule.

In the 2019 Physician Fee Schedule (“PFS”) Proposed Rule, the Centers for Medicare and Medicaid Services (“CMS”) proposed some major changes to the PFS, including changes to the way Evaluation and Management (“E/M”) services are reimbursed. The PFS Final Rule[1] contains some good news and bad news. The good news . . . CMS isn’t making any of the major changes it proposed in 2019. The bad news . . . they plan on making some big changes over the next few years.

<<Quick Summary: 2019 Medicare Physician Fee Schedule and Quality Payment Program Final Rule>>

Proposal

CMS proposed to collapse several levels of E/M Codes into one reimbursement level with add-on codes for certain prolonged or complex visits.

Final Rule

CMS is reducing some documentation redundancies for 2019, but it is not finalizing most of the payment proposals described above until 2021.

The Details

Currently, there are 3 to 5 levels of E/M codes depending on the practice setting (3 to 4 in facility settings and 5 for outpatient or office settings). These codes are billed based on the relative complexity of the E/M service provided, as determined in accordance with either the 1995 or 1997 guidelines issued by CMS.[2] The higher the level of E/M service (and associated relative time and resources required to deliver those services), the higher the reimbursement. According to CMS, E/M codes represent approximately 40 percent of allowed charges for PFS services, and outpatient/office visit E/M codes represent about 20 percent of total PFS allowed charges. Despite the frequency with which E/M services are performed and billed, there are a number of complexities surrounding how they are billed and the documentation required for each level of E/M code.

In an effort to alleviate this burden, CMS proposed to collapse the reimbursement for E/M level 2 through level 5 codes into a single reimbursement amount. In addition, CMS proposed to allow two new add-on codes to represent prolonged services and services with a relatively high degree of complexity. Noting the extensive time and resources that will be needed to adjust to the new coding regime, CMS has delayed the effective date of these rules until 2021. There’s time to prepare for the new E/M coding regime, and it may be altered some between now and 2021, but below is a brief overview of the finalized changes for 2021.

Collapsing Reimbursement for Levels 2-4. Importantly, CMS decided not to change the E/M codes themselves but instead chose to pay the same base reimbursement for E/M code levels 2 through 4.[3] In theory, this will reduce the level of documentation required because physicians will only need to meet the documentation requirements for a level 2 E/M code. However, it will also result in a reduction in reimbursement for many physicians who ordinarily bill higher level E/M codes, unless they also bill for one of the new add-on codes discussed below. Despite the changes in reimbursement levels, physicians do not necessarily have to change how they perform and document E/M services. In fact, CMS expects that physicians will continue to document and bill as they normally would. Noting that other government and private payors (including Medicaid, Blue Cross & Blue Shield, etc.) may continue to use the existing coding structure—or would at least need time to adjust to new coding regimes — CMS decided to retain the existing coding structure, changing the reimbursement only.

Add-On Codes. To account for the reduction in reimbursement associated with the new combined reimbursement rate for E/M levels 2 through 4 and to better align reimbursement with the resources utilized in providing E/M services, CMS decided to add two new add-on codes (again, effective 2021) that can be billed with E/M levels 2 through 4. The first is an add-on code for E/M visits for primary care and certain types of specialized medical care. The second is an add-on code to account for additional resources utilized when physicians have extended visits with patients. Despite the addition of these new codes, CMS indicated that there should not be any additional documentation requirements for E/M services.

Reducing Redundant Data Recording (effective 2019). In response to stakeholder feedback, CMS decided to remove the requirement that physicians document the medical necessity of conducting a visit in the patient’s home instead of in the physician’s office.[4] CMS also decided to streamline documentation requirements by allowing physicians to review information already contained in the medical record (review of systems and past, family and/or social history) and update it as needed, rather than re-recording all of the information.

Proposals Not Adopted. CMS decided not to adopt some of its proposals, including proposals to: (1) reduce reimbursement when E/M services are provided on the same day as a procedure; (2) establish separate podiatric E/M codes; and (3) standardize the amounts of practice expense RVUs for E/M codes.

Conclusion

Overall, there are some changes going into effect in just over a month, and others will likely be reshaped and refined over the next two years before they are implemented in 2021. For now, all physicians need to know is that they can continue to document and bill E/M codes as they always have, but in theory with less redundancy in documentation requirements.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

 

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[3] CMS decided to combine levels 2 through 4 instead of 2 through 5, as originally proposed.

[4] CMS reasoned that this decision is best left to the physician and patient, without applying additional payment rules.

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CMS Releases Physician Payment Rule

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CMS Releases Physician Payment Rule

This week CMS released the final physician payment rule for CY 2019. In addition to the changes to the physician fee schedule (slightly higher than the CY 2018 rate), the rule expands payment for telehealth and aligns physician interoperability requirements with hospital requirements and allows more flexibility in the physician quality reporting program. The rule finalizes a consolidated payment rate for evaluation and management (E/M) office and outpatient visit levels 2 through 4, while maintaining the payment rate for level 5 E/M visits. It also reduces payment for new Part B drugs and requires hospital outreach laboratories to begin collecting and reporting private payer payment rates and volumes. Finally, the rule will continue to allow non-excepted off-campus provider-based departments of hospitals to bill for non-excepted services on the institutional claim and will maintain payment for non-excepted services at 40 percent of the outpatient prospective payment system amount for CY 2019.

The Medical Association partnered with the American Medical Association to secure the changes.

Removing Restrictions on E/M Coding

CMS finalized several changes to E/M documentation guideline which were strongly supported by the AMA and other members of the Federation:

  • The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated.
  • Physicians will no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated. In addition,
  • Physicians must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the patient.
  • These changes will take effect 1/1/2019.

The Original Proposal Condensing Office Visit Payment Amounts and Documentation Requirements

In the 2019 proposed rule, CMS proposed to implement a single payment rate for level 2 through level 5 office visits and to reduce documentation requirements for this collapsed payment to that of a level 2 CPT visit code. The Agency proposed to continue to use existing CPT structure for office visit codes 99201-99215, though proposed to change CMS guidelines and only enforce certain aspects of the CPT structure by allowing physicians to choose the method of documentation, among the following options:

  • 1995 or 1997 Evaluation and Management Guidelines for history, physical exam and medical decision making (current framework for documentation)
  • Medical decision making only
  • Physician time spent face-to-face with patients
  • CMS had also proposed an add-on code to each office visit performed for primary care purposes and an add-on code for specialities with inherently complex E/M visits
  • CMS relayed that commenters overwhelmingly opposed the Agency’s proposed payment collapse. CMS will not finalize the proposal for CY 2019.

Other Coding/Payment Proposals Related to E/M

The following policies were also opposed and will not be implemented by CMS:

  • Payment reductions by 50 percent for office visits that occur on the same date as procedures (or a physician in the same group practice). The AMA brought attention to the fact that duplicative resources have already been removed from the underlying procedure through the current valuation process.
  • In addition, CMS proposed to no longer allow for podiatry to report CPT codes 99201-99215 and instead would use two proposed G-codes for podiatry office visits. As well as a new prolonged service code that would have been implemented to add-on to any office visit lasting more than 30 minutes beyond the office visit (ie, hour long visits in total).
  • Condensed practice expense payment for the E/M office visits, by creating a new indirect practice expense category solely for office visits, overriding the current methodology for these services by treating Office E/M as a separate Medicare Designated Specialty. This change would also have resulted in the exclusion of the indirect practice costs for office visits when deriving every other specialty’s indirect practice expense amount for all other services that they perform, which would have resulted in large changes in payment for many specialties (ie a greater than 10 percent payment reduction for chemotherapy services).

Download the CMS Factsheet.

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CMS Updates LCD Determination Process

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CMS Updates LCD Determination Process

On Oct. 3, 2018, the Centers for Medicare and Medicaid Services announced updates to Chapter 13 of the Medicare Program Integrity Manual, which deals with Local Coverage Determinations. According to CMS, the updates are intended to “increase transparency and patient engagement.”[1]  These changes call for informal meetings with interested parties before a formal request is submitted to the Medicare Administrative Contractor.  Educational meetings can be held in local jurisdictions and can be either in-person, teleconference or web-based.  Additionally, the changes to the manual set forth a roadmap for how the MAC issues an LCD.

LCDs are issued by MACs when there is no national determination on whether an item or service is covered. The idea is that the regional MACs will take into account local variations in the practice of medicine when issuing the LCD. For example, Palmetto GBA, Alabama’s MAC for Medicare Part A and B has issued an LCD on allergy testing (L33417).

According to a Medicare Learning Network publication[2], CMS’s updates were a result of feedback from providers and healthcare associations who were concerned that beneficiaries were not receiving necessary products and procedures due to deficiencies in the LCD process, such as notification of revisions to and drafting of LCDs. The new LCD process is intended to allow for more interaction with stakeholders before and during LCD development.

The “Roadmap”

1)         Requests for LCD

MACs will consider requests from beneficiaries residing or receiving care in the MAC’s jurisdiction, health care professionals doing business in the MAC’s jurisdiction or any interested party doing business.

A request is deemed complete if the request:

  • Is in writing and is sent to the MAC via e-mail, facsimile or written letter.
  • Clearly identifies the statutorily-defined Medicare benefit category to which the item or service applies.
  • Identifies the language the requestor wants in an LCD.
  • Includes justification supported by peer-reviewed evidence. Full copies of the published evidence must be included.
  • Addresses relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service.
  • Fully explains the design, purpose, and/or method as appropriate of using the item or service for which the request is made.

2)         Consideration of the LCD

The new guidelines suggest that MACs supplement the requests or proposed LCDs with clinical guidelines, consultation with experts, medical associations or other health care professionals.  This information is to be summarized prior to drafting or finalizing the LCD.

3)         Publication

A proposed LCD will be published on the Medicare Coverage Database (MCD) website at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Once published, MACs will allow 45 days for public comment.  There are some exceptions to the publication requirement.

4)         Contractor Advisory Committee (CAC)

A CAC will be established from each state and will be composed of healthcare professionals, beneficiary representatives and representatives of medical organizations.  The purpose of the CAC is to assist in the evaluation of the evidence in developing LCDs and communicate between the MACs and healthcare community.  This is an advisory committee with the ultimate authority residing with the MACs.

5)         Open Meetings

After the LCD publication, the MAC will hold an open meeting to discuss the rationale and evidence supporting the LCD.  Interested parties can also make presentations at these meetings.  The date and location of the meetings must be publicized by the MAC.

6)         Publication of Final Determination

After the close of the comment period and the required public meeting, the final LCD and Response to Public Comment will be published on the MCD (see link above).  MACs must respond to all comments received during the comment period.

7)         Notice Period

The date the final LCD is published on the MCD marks the beginning of the required notice period of at least 45 days before the LCD can go into effect.  If the notice period is not extended by the MAC beyond the 45 days, the LCD is effective on the 46th calendar day.

Additional changes include the retirement (or expiration) of all proposed polices if not finalized within one year after the original posting date and a removal of all ICD and CPT codes from LCDs.

For more information on the changes to Chapter 13, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf.

[1] CMS Accelerates Innovation and Promotes Patient Access to Medical Technology, https://www.cms.gov/newsroom/press-releases/cms-accelerates-innovation-and-promotes-patient-access-medical-technology

[2] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Angie Cameron Smith is an attorney at Burr & Forman LLP practicing within the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

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