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Coding Corner

CMS Proposal
CY 2019 Proposed Rule.

  • Eliminating Prohibition on Billing Same-Day Visits by Practitioners of the Same Group and Specialty.
    • Current processing state - “As for all other E/M services except where specifically noted, MAC may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, provided during the same encounter”.
    • Proposal
      • Eliminating this policy would recognize the changing practice of medicine while reducing the administrative burden.
        • Recognize practitioners who have multiple specialty affiliation but only one primary specialty with Medicare enrollment
        • No longer inconvenience patients by scheduling visits on separate days
      • CMS is soliciting public comment to determine if they should consider creating exceptions to or modify this manual provision rather than eliminating it entirely.
      • CMS requesting provide additional examples and situations in which the current process is not clinically appropriate.
  • Medical Decision Making, Time or Current Framework
    • Current guidelines are outdated with respect to the current practice of medicine.
    • Proposal would allow practitioners to use MDM, or time, or continue to use the current framework under the 1995 or 1997 guidelines to document the E/M visit.
    • Proposal would retain the current CPT coding structure for E/M visits (along with creating new replacement codes for podiatry office/outpatient E/M visits).
    • Would only apply to office/outpatient visit codes (CPT 99201 through 99215) except specified otherwise.
    • Practitioners may use either the 1995 or 1997 versions of the E/M guidelines to document E/M visits billed to Medicare.
  • Removing Redundancy in E/M Visit Documentation
    • The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. 
    • There must be a notation supplementing or confirming the information recorded by others.
    • To simplify the documentation of history and exam for established patients, practitioners would only be required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed by noting the date and location of earlier ROS and/or PFSH.
    • For both new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the chief complaint and history that are already entered by ancillary staff or the beneficiary. The practitioner could indicate in the medical record that they reviewed and verified the information. For new patients, prior data must be in EHR or other data exchange.
  • Podiatry Visits
    • Propose to create separate coding for podiatry visits that are currently reported as E/M office/outpatient visits.
    • Podiatrists would report visits under new G-codes that more specifically identify and value their services.
      • GPD0X (podiatry services, medical examination and evaluation with initiation of diagnostic and treatment program, new patient)
        • wRVU 1.35
        • Physician time of 28 minutes
      • GPD1X (Podiatry services, medical examination and evaluation with initiation of diagnostic and treatment program, established patient)
        • wRVU .85
        • Physician time of 22 minutes
  • Minimizing Documentation Requirements by Simplifying Payment Amounts
    • Propose to simplify the payment for those E/M outpatient/office services by paying a single rate for the level 2 through level 5 E/M visits. 
    • Documentation requirements for E/M levels such that the practitioners have the choice to use the 1995 guidelines, the 1997 guidelines, time, or MDM to determine the E/M level.
    • Propose to develop a single set of RVU’s under the PFS for E/M office-based and outpatient visit levels 2 through 5 for new patients (CPT 99202 through 99205) and single set of RVU’s for visit levels 2 through 5 for established patients (CPT 99212 through 99215).
      • Practitioners would continue to bill the CPT code for whichever level of E/M service they furnished, and they would be paid the single PFS rate.
    • Propose wRVU of 1.90 for CPT codes 99202-99205 (new patients).
    • Propose wRVU of 1.22 for CPT codes 99212-99215 (established patients).

Preliminary Comparison of Payment Rates for OV – New Patients

HCPCS Code CY 2018 Non-facility Payment Rate Cy 2018 Non-facility Payment Rate under the proposed Methodology Current wRVU value Proposed wRVU value wRVU Change
99201 $45 $44 .48 .48 0
99202 $76 $135 .93 1.90 +.97
99203 $110 $135 1.42 1.90 +.48
99204 $167 $135 2.43 1.90 -.53
99205 $211 $135 3.17 1.90 -1.27

Preliminary Comparison of Payment Rates for OV – Established Patient

HCPCS Code CY 2018 Non-facility Payment Rate Cy 2018 Non-facility Payment Rate under the proposed Methodology Current wRVU value Proposed wRVU value wRVU Change
99211 $22 $24 .18 .18 0
99212 $45 $93 .48 1.22 +.74
99213 $74 $93 .97 1.22 +.25
99214 $109 $93 1.50 1.22 -.28
99215 $148 $93 2.11 1.22 -.89

Unadjusted Estimated Specialty Impacts of Single PFS Rate for Office/Outpatient E/M Levels 2 through 4

Specialty Allowed charges (millions) Impact
Podiatry $2,022 10%
Dermatology $3,525 6%
Hand Surgery $202 5%
Oral/Maxillofacial Surgery $57 4%
Otolaryngology $1,220 -4%
Cardiology $6,723 -3%
Hematology/Oncology $1,813 -3%
Neurology $1,565 -3%
Rheumatology $559 -6%
Endocrinology $482 -8%

Note: All other specialty level impacts were within +/- 3

This table shows that specialties that bill more higher level visits do not benefit by maintaining a distinct payment for level 5 visit.

  • Recognizing the Resource Costs for Different Types of E/M Visits
    • 3 types of E/M visits that differ from the typical E/M service
      • Separately identifiable E/M visits furnished in conjunction with a 0-day global procedure
      • Primary care E/M visits for continuous patient care
      • Certain types of specialist E/M visits, including those with inherent visit complexity.
    • Proposal
      • E/M multiple payment procedure adjustment to account for duplicative resource costs when E/M visits and procedures with global periods are furnished together.
      • HCPCS G-code add-ons to recognize additional relative resources for primary care visits and inherent visit complexity that require additional work beyond that which is accounted for in the single payment rates for new and established patient levels 2 through level 5 visits
      • HCPCS G-codes to describe podiatric E/M visits
      • An additional prolonged face-to-face services add-on G code
      • Currently standalone E/M visits codes are not billable on the same day as the procedure codes unless the billing professional specifically indicates that the visit is separately identifiable from the procedure (25 modifier)
        • Propose to make payment for the E/M levels 2 through 5 at a single PFS rate, we would reduce payment by 50% for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier -25.
  • Proposed HCPCS G-code Add-ons to Recognize Additional Relative Resources for Certain Kind of Visits
    • Proposed value for the single payment rate for E/M levels 2-5 new and established patient visit codes does not reflect these additional resources inherent to primary care visits (primary care visits are generally reported using level 4 E/M codes.
      • Proposed value for the single payment rate for E/M levels 2-5 new and established patient visit codes does not reflect these additional resources inherent to primary care visits (primary care visits are generally reported using level 4 E/M codes.
        • Create a HCPCS add-on G-code (GPC1X – visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services) to adjust payment to account for additional costs beyond the typical resources accounted for in the single payment rate for levels 2- 5 visits.
          • Proposed wRVU of .07.
        • Create a HCPCS add-on G-code (GCG0X – visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care).
          • Proposed wRVU of .25
  • Proposed HCPCS G-Code for Prolonged Services
    • Propose to create a new HCPCS code GPR01 (prolonged evaluation and management or psychotherapy services beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; 30 minutes.  List separately in addition to code for office or other outpatient E/M or psychotherapy service.
      • Proposed wRVU of 1.17
  • Proposed Implementation Date
    • Propose that these proposed E/M visit policies would be effective January 1, 2019.
  • Teaching Physician Documentation Requirements for Evaluation and Management Services
    • Currently, for certain procedural services, the participation of the teaching physician may be demonstrated by the notes in the medical records made by a physician, resident or nurse; and for E/M visits, the teaching physician is required to personally document their participation in the medical record.
    • Propose that the medical record must document the extent of the teaching physician’s participation in the review and direction of services furnished to each beneficiary and that the extent of the teaching physicians’ participation may be demonstrated by the notes in the medical record made by a physician, resident or nurse.
  • Comment period ends September 10, 2018

 








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