Major Changes Coming to 2021 E/M Coding

Considerable changes are being made to Medicare outpatient evaluation and management (E/M) codes. The transition will take effect on January 1, 2021 and will likely affect physicians across all specialties.

The changes are currently restricted to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will impact everyone who assigns codes, manages patient information, or pays claims including physicians, health information managers, coders, payers, health systems, and hospitals. 

Why was modification needed?

Because of advocacy by the Medical Association and other organizations, the Centers for Medicare and Medicaid Services (CMS) adopted a revised E/M documentation methodology proposed by the American Medical Association (AMA). 

The goal of the suggested adjustments is to reduce physician burden by simplifying documentation requirements and administrative responsibilities. By reducing managerial concerns, physicians will have the ability to spend more in-depth, quality time with their patients. 

What are the changes?

There will be various changes to office and outpatient E/M visits. However, the most notable is the removal of the Level 1 new patient visit (99201), a new 15-minute extended services code that can be used with codes 99205 and 99215, and the following modifications of office code selection:

• History and physical exams are no longer elements for code selection
• Physicians can choose to use total time or medical decision making as the basis of their E/M documentation
• Medical decision-making criteria has been revised and clarified
  • Removed ambiguous terms and concepts
  • Defined vague terms
  • Re-established data elements to move away from adding up tasks and instead focusing on how those tasks affect the patient’s care

What can you do to prepare?

• Visit our website to find more resources on the 2021 E/M coding and guideline changes
• Watch our NEW Online E/M Coding Changes for 2021 webinars hosted by Dr. Thomas Weida and Kim Huey and earn CME
• Contact your medical billing company and/or coders to develop a plan for training office staff to ensure a smooth transition at the first of the year
• Connect with your Electronic Health Records (EHR) provider to confirm that your practice’s system will be ready to implement the new coding changes
• Reach out to your payers to negotiate implementing the new E/M rates

With changes this substantial, we encourage you to prepare early. Watch for more information in the coming weeks on our website and email alerts. If you have further questions, please email us at staff@alamedical.org.

Discussions with Decisionmakers: Finance Director Kelly Butler

About Kelly Butler:

Kelly Butler was appointed as the Director of the Alabama Department of Finance by Governor Kay Ivey on December 1, 2018, after serving as acting State Finance Director since August 15, 2018. As the State’s chief financial officer, Butler serves as an advisor to the governor and the Legislature in all financial matters and is charged with protecting the financial interests of the State of Alabama. He is responsible for the administration and oversight of the Department of Finance and serves on various advisory boards and authorities.

Butler has worked for the state of Alabama for over 30 years and previously served as Assistant State Finance Director for Fiscal Operations since December 2016. Mr. Butler was also the State Budget Officer since June 2014. Prior to his employment with the Finance Department, he worked for 19 years with the Legislative Fiscal Office, most recently serving as the Senate Fiscal Officer. Earlier in his career, Mr. Butler worked as a revenue examiner with the Alabama Department of Revenue, where his duties included serving as a corporate income tax and financial institution excise tax auditor and serving as an assistant to the Chief of the Income Tax Division.

Mr. Butler is a graduate of Auburn University Montgomery (BSBA) and Troy University (MBA).

COVID-19 Grant Program

As the Alabama Director of Finance, Mr. Butler is in charge of overseeing the disbursement of all COVID-19 funds received via the CARES Act, including the new Health Care and Emergency Response Providers Grant Program. We recently hosted a Zoom call with Mr. Butler to discuss this program and answer any questions Alabama physicians might have.

Simply click the video below to begin watching where the Q&A with Mr. Butler begins.

Medical Association Recognizes Racism as a Threat to Public Health

At the most recent Board of Censors meeting, the Medical Association of the State of Alabama pledged to recognize and confront racism and racial inequalities within our society and the healthcare system. The Medical Association further recognizes the need to end systemic racism in our country and to work towards a better, fairer, and more just society. 

The Medical Association released the following statement following their meeting last week:

• The Medical Association opposes all forms of racism
• The Medical Association considers racism a public health crisis and a threat to public health
• The Medical Association understands the elimination of health disparities will not be achieved without first acknowledging the contributions of all races to health and social inequalities
• The Medical Association understands that we have a responsibility to actively work to eliminate discriminatory policies and practices across all of healthcare
• The Medical Association supports ending racial discrimination in medical care and the equitable access to quality health care services
• The Medical Association encourages current and future physicians to be advocates for justice

We recognize that worsening inequities, unequal access to care, and the racial disparities of practicing physicians all have roots in systemic racism and must be confronted. The Medical Association of the State of Alabama understands that there is still tremendous work to be done to ensure that everyone has the opportunity, resources, and conditions to achieve optimal health. The Medical Association is committed to being a part of that solution.

Sincerely,

President John S. Meigs, MD and Board of Censors

Medical Cannabis Passes Senate Committee

Last Wednesday, the Alabama Senate Judiciary Committee advanced a bill allowing cannabis to be recommended for up to 15 conditions for medicinal purposes.

SB165, informally named the Compassion Act and sponsored by Sen. Tim Melson, M.D., would allow physicians to recommend medical cannabis for conditions such as cancer, anxiety and chronic pain. It would also let patients with state-issued cannabis cards to purchase cannabis products at licensed dispensaries. Cannabis products dispensed to patients would be under strict state regulation from seed to sale, including testing products for consistency and to ensure no contamination.

Under Melson’s bill, medical cannabis would available to anyone 19 years or older whom a physician certifies as having a qualifying medical condition. Patients 18 or younger would need a parent or guardian to administer cannabis. The patient would have to apply for a medical cannabis card, which would cost no more than $65.

Cannabis will only be available in encapsulated form or a topical agent. The bill would also establish a fund using tax proceedings for increased research on cannabis.

Having passed the Judiciary Committee 8-1, the legislation will now receive a vote before the entire Senate. Should it pass the Senate, it still must go to through a committee and floor vote in the House.

After surveying its members, the Medical Association found Alabama physicians believe if cannabis for medicinal use is legalized, then the growth, cultivation and sale of cannabis should be highly regulated by the state, and any physician involvement should be regulated not by some new state agency, but by the Board of Medical Examiners. Likewise, the survey found physicians believe any administration or use of legalized medical cannabis should be limited to encapsulated form and topical agents.

While there was no overwhelming consensus found regarding physicians’ support or opposition to the legalization of medicinal cannabis, the Medical Association has worked tirelessly with the bill sponsor to bring the legislation in line with the areas of broad agreement in our member survey. We appreciate the willingness of Sen. Melson in working with us and will continue monitoring the bill as it moves forward.

Senate Committee Approves Collaborative Practice Ratio Increase

Last Wednesday, the Senate Health Committee approved an amended version of legislation dealing with the ratio of physicians to nurse practitioners in a collaborative practice.

Originally, the bill would have allowed physician collaboration with an “unlimited” number of full-time equivalent nurse practitioners or nurse-midwives. However, after significant input from the Medical Association, the legislation deletes “unlimited” and instead increases the number of nurse practitioners and physician assistants with whom a physician may collaborate.

Specifically, the amended legislation:

• Deletes “unlimited” and instead increases the current ratio of FTEs from 1:4 to 1:9;
• Adds physician assistants to the total collaborative ratio;
• Maintains the collaborating physician’s autonomy and authority within the collaborative practice agreement;
• Maintains the ability for exceptions to this new 1:9 ratio through regulation; and,
• Maintains the current regulatory structure for physician assistants, nurse practitioners, nurse midwives, and collaborating physicians.

Collaborative practice is not “one-size-fits-all” and this newly-amended bill allows for flexibility in collaboration while also preserving physician authority. The compromise was a joint effort between the Medical Association, the Nurse Practitioners Alliance and the Alabama Physician Assistants’ Association. We now support this legislation.

The legislation (SB114) now moves to the Senate floor for a vote.

Proposed Importation of Prescription Drugs from Canada

On December 18, 2019, the Food and Drug Administration (“FDA”) issued a proposed rule (the “Proposed Rule”) to amend its regulations to implement a provision of the Federal Food, Drug, and Cosmetic Act to allow importation of certain prescription drugs from Canada.  The purpose of the Proposed Rule is to lower prices and reduce out-of-pocket costs for American patients.  If the Proposed Rule is finalized as proposed, States or certain other non-federal governmental entities and their co-sponsors, if any (collectively “Sponsors”), would be able to submit drug importation program proposals (each a “Drug Importation Proposal”) to the FDA for review and authorization.  If a Drug Importation Proposal were approved, it would be authorized for a 2-year period, with the possibility of extensions for additional 2-year periods. 

The Proposed Rule would require each Drug Importation Proposal to:

• Specify the eligible prescription drug the Sponsor seeks to import;
• Demonstrate that the proposed importation program will pose no additional risk to the public’s health and safety;
• Provide an explanation as to why the Sponsor expects the importation program would result in a significant reduction in the cost of such prescription drug to the American consumer; and
• Identify the foreign seller in Canada that would purchase the drug directly from its manufacturer and the importer in the United States that would buy the drug directly from the foreign seller. The foreign seller must be registered with the FDA as a foreign seller and be licensed by Health Canada as a wholesaler, and the importer must be a State or FDA licensed wholesale drug distributor or State-licensed pharmacist.

At least one State, tribal, or territorial governmental entity would be required as a Sponsor of a Drug Importation Proposal to offer enhanced accountability and to protect the public health.  Co-sponsorship is included in the Proposed Rule to allow the State, tribal, or territorial governmental entity to benefit from the experience of pharmacists and wholesalers. 

To be eligible to be imported, a prescription drug would need to be approved by the Health Products and Food Branch of Health Canada and, but for the fact that it deviates from U.S. labeling, also meet the conditions in an FDA-approved new drug application or abbreviated new drug application.  Essentially, eligible prescription drugs are those that could be sold legally on either the Canadian market or the American market with appropriate labeling.  An eligible prescription drug would need to be relabeled with the required U.S. labeling, prescribing information, and patient information before sold in the United States. Also, to be eligible for importation, the prescription drug must be currently marketed in the United States (which would allow the FDA to be better able to determine if there is a safety issue with an imported drug).  Several categories of prescription drugs are excluded from the Proposed Rule including controlled substances, biological products, infused drugs, intravenously injected drugs, and drugs that are inhaled during surgery. 

The FDA is seeking comments on the Proposed Rule until March 9, 2020.  Stay tuned for updates as to whether or not the Proposed Rule is revised or finalized as proposed. 

Anthony Romano practices with Burr & Forman LLP in the firm’s Health Care Industry Group. Anthony may be reached at aromano@burr.com.

Competing Surprise Billing Measures Released

Early this week, Senator Lamar Alexander (R-TN), the Chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee, and Representatives Frank Pallone (D-NJ) and Greg Walden (R-OR), the Chairman and Ranking Member of the House Energy and Commerce Committee announced an agreement on legislation to end surprise medical bills. The two members issued a joint press statement with the hope of creating momentum to include their legislative agreement as part of any year-end omnibus appropriations bill.

The agreement is essentially a merging of the surprise billing legislation approved by both the House Energy and Commerce (H.R. 2328) and Senate HELP Committees (S.1895) earlier this year. Both bills aim to protect patients by limiting their out-of-pocket costs to amounts they would have owed if they had been treated by an in-network physician. However, both bills include provisions strongly opposed by physician and hospital groups (including the Medical Association of the State of Alabama) that would resolve payment disputes between physicians and insurers by using a benchmark rate setting out-of-network payments at the median amount each insurer pays for in-network care. The new agreement includes similar benchmark rate provisions as well as a very limited independent dispute resolution process with a $750 threshold that would only allow for the consideration of median in-network rates.

It was believed by many early in the week, that the surprise billing agreement would pass before the end of the year. However, the House Ways and Means Committee also has jurisdiction over the surprise billing issue and the committee was not included in this initial agreement. Ways and Means subsequently released its own bipartisan proposal that focuses on an arbitration process that protects the patient and said that the committee will consider the legislation in early 2020. With competing bipartisan bills now on the table, it is likely that any action on the legislation will be delayed until January.