Medicare Breaking News: The Release of the Final Rule

Dec 8, 2020 | Uncategorized

Medicare released a physician fee schedule on December 1st that is set to take effect on January 1st, 2020. The release of the Final Rule delivers a 10.2% drop in the Conversion Factor. Most other E/M revisions remain on track with the AMA. Continue reading below to learn more.nnby: Ginger Avery, CPC, CPMA, CRC 12/2/2020nAccording to the 2021 Medicare physician fee schedule released on December 1st , starting Jan. 1, 2021, clinicians are facing a 10.2% drop in the Medicare conversion factor, finalized at $32.41. This CF decrease will result in an up-and-down projection in 2021 for medical specialties. CMS states the cut is needed as a counterweight to the increased fees for E/M officenvisit codes (99202-99215), which account for 20% of fee schedule spending.n

Source: Final 2021 Medicare physician fee schedule, released Dec. 1

nThe final rule confirms that CMS has adopted relative value units (RVU) approved by the AMA. The new valuations boost total RVUs for nearly all of the office visit codes and elevate RVUs for established office codes 99212-99215 by an average of 28%.nnDue to the CF reduction, office visit codes will see a diminished payment increase in 2021. For example, reimbursement for new patient E/M codes 99202-99204 will be reduced. Established office visit codes will see an increase in the range of 11% to 15%. Coding patterns are expected to shift to higher levels of service based on the new guidelines.n

Source: Final 2021 Medicare physician fee schedule

nAccording to data contained in the final fee schedule, specialties that will see a positive outcome with the new CF includes: endocrinology (+16%), rheumatology (+15%), hematology/oncology (+14%) and family practice (+13%). Specialties that are on pace for pay cuts include radiology (-10%), chiropractor (-10%), nurse anesthetist (-10%) and physical and occupational therapy (-9%).nnIn 2021, either medical decision-making (MDM) or time will drive code selection for E/M office visit codes. Medically appropriate history and/or exam will be the new accepted practice. CMS states. “We continue to believe these policies will further our ongoing effort to reduce administrative burden, improve payment accuracy, and update the O/O E/M visit code set to better reflect the current practice of medicine.”nnCMS Replaces Prolonged Service Code 99417 with HCPCS Code G2212nCMS made the decision to issue a new HCPCS code, G2212, instead of 99417, for prolonged services when reporting based on time. As expected, CMS did not agree with the AMA’s final descriptor for 99417, and is requiring the visit to exceed the maximum time for 99205 and 99215 to be met before capturing G2212 , unlike AMA’s guidance to meet the minimum time before capturing prolonged service time.nnThe descriptor for Medicare’s new prolonged services code G2212: “Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes).”nnCheck with your commercial/private payers that may prefer the G code. Reach out to your software vendors to assure your systems are ready to capture these new codes. If your organization has not received training on the upcoming changes for E/M office visits services, now is the time, contact WHP for details.nnVisit Complexity Add-on HCPCS Code G2211 Enters the Coding ArenanAlthough it is not yet clear as to appropriate application, CMS will roll out add on code +G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. CMS stated in the final rule that the new add-on code will be appropriate for 90% of E/M office visit encounters and is appropriate for both new and established patients.nnTelehealth Rule Changes During/After COVIDnCMS finalized 114 Category 2 codes for telehealth – i.e., codes cleared for use outside of the restrictive distant-and-originating-site requirements and eligible for other flexibilities under the public health emergency (PHE). The agency also added a new “Category 3” of codes that “will remain on the list through the calendar year in which the PHE ends.” The bad news is these codes will eventually go back to the old telehealth rules if Congress does not change the law.nnCMS states it will conduct “a commissioned study, analysis of Medicare claims data or another assessment mechanism, to further study the impacts of this limited permanent expansion of the virtual presence policy to inform potential future rulemaking, and in an effort to prevent possible fraud, waste and abuse.”nnTelephone Visits New G codenCMS finalized its decision to cease separate payment for CPT telephone E/M codes 99441-99443 once the PHE ends. For the remainder of 2021, CMS created an interim code, G2252, for a “brief communication technology-based service (e.g., virtual check-in)” for established patients only. The code is priced at the same amount as CPT telephone visit code 99442 and covers 11-20-minute “medical discussion,”.nnCMS states that the G2252 service applies when a patient reports an exacerbation of an ongoing problem and wants to know whether a face-to-face office visit is warranted. CMS does not consider a telephone visit to be a substitute for an E/M service but instead “an assessment to determine the need for one.”nnCode G2252 will therefore be considered a communications technology-based service (CTBS) similar to a virtual check-in, not a telehealth service. Like the CPT phone codes, it will not be separately reported if the call occurs within seven days after a previous in-person visit or within 24 hours “or soonest available appointment.”nnRemote Patient MonitoringnCMS also finalized PHE flexibilities in remote patient monitoring codes: For example, while “only physicians and NPPs [non-physician providers] who are eligible to furnish E/M services may bill RPM services,” auxiliary personnel, including contract employees, may provide RPM services incident to under codes 99453 and 99454. Once the PHE ends, many of the current flexibilities will, too: For example, established patient-physician relationship will once again be required to initiate RPM services.nnThe waiver for direct supervision of NPPs by a physician using real-time, interactive audio and video technology is cleared through “the latter of the end of the calendar year in which the PHE ends or December 31, 2021.”nnCMS added some new virtual services that NPPs will be eligible to provide G2250 (Remote assessment of recorded video and/or images submitted by an established patient) and G2251 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional) for providers that cannot bill E/M services.nnTransitional Care ManagementnAs part of its ongoing quest to boost utilization of transitional care services (99495-99496), CMS is unbundling 14 end-stage renal disease (ESRD) codes and chronic care management (CCM) code G2058 – which will be replaced with 99439 next year – from the service.nnThis is a breaking news story. Please check CMS for additional updatesnnSee DecisionHealth’s Blog for more details.