- CMS rescinds bundled payments for 2021 and accepts CPT® revisions for new and established patients
- Proposes new HCPCS codes for care management
- Outlines proposals to further ease burden of documentation
As I work my way through the proposed rule, I’ll add new content at the top of this blog post. The 2020 proposed physician fee schedule rule is the subject of August’s webinar. These are proposals—the final rule is released in November.
E/M changes for 2021
The biggest news in the 2020 proposed physician fee schedule has an effective date in 2021. Last year, CMS said that it would implement a single payment and RVU value for codes 99202—99204 and another for codes 99212—99214.
Then, CPT® released revisions to the new and established patient rules effective in 2021. CMS is accepting those changes and is not going to implement the plan for a single fee/RVU value for those code ranges.
In addition, beginning in 2021, neither history nor exam will be a key component for codes 99202—99215. 99201 will be deleted in 2021. Code selection will be based on either time, with new rules related to counting time for these services, or a re-defined medical decision making. If you attended July’s webinar, you heard the details.
CMS proposing new care management codes
CMS is proposing to add new HCPCS codes to replace the current chronic care management codes, 99490, 99487 and 99489. This would most likely be for only one year, because CMS anticipates that the CPT® editorial panel will work on these codes for the future.
CMS does not come out and say that they expect CPT® to develop CPT® codes to replace the HCPCS codes, but reading between the lines, that is the implication. CMS is proposing two codes to replace 99490. CMS is proposing that one code would be equivalent to 99490, the first 20 minutes in a calendar month, but they would add a second code for each additional 20 minute increments of clinical staff time.
They’re seeking comments on whether to limit the number of additional increments of the add-on code that would be allowed.
They are proposing replacing 99487 and 99489 with HCPCS codes that would have the same time increments, and which would slightly decrease the difficulty of reporting complex chronic care management. It would no longer require a substantial care plan change in order to bill it.
Principal care management
CMS is also proposing to add an additional two HCPCS codes for principal care management. The first is defined as:
“Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.”
That code may be used by a physician, nurse practitioner, or a physician assistant.
There is an additional proposed code for use by clinical staff members.
“Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.”
A patient would be eligible for principal care management (PCM) if they have only one chronic condition that is expected to last between three months and a year or until the death of the patient. It would be a condition that had led to a recent hospitalization and/or places the patient at significant risk of death, acute exacerbation/decompensation or functional decline.
CMS is not proposing any restrictions on specialties they could bill PCM, but expects that this code would be billed by specialists, when there is a single condition of such complexity that it cannot be managed in a primary care setting.
Transitional care management (TCM) changes
CMS is proposing to increase work RVUs for TCM. In addition, they note that there are currently 57 services that may not be billed during the TCM period, per CPT®. Many of these are noncovered, bundled, or invalid for Medicare purposes, but not all.
CMS is proposing to allow 14 CPT® or HCPCS to be billed within the TCM period, that are now prohibited by CPT® from being reported together, codes which may not be billed currently with TCM to be billed with TCM.
Supervision of physician assistants
Although the billing rules under Medicare for nurse practitioners, certified nurse midwives, and physician assistants are the same, the supervision rules are different for physician assistants. CMS is proposing to change that. They’re proposing that supervision requirements would be met when a PA is performing services in their state scope of practice and provided with medical direction and appropriate supervision as required by the state in which the physician assistant is practicing.
Medical record documentation
CMS notes that they have received questions from stakeholders about whether PA and NP students are covered in the definition of a student under the teaching physician roles. They note that currently and NP or PA preceptor may not use the note of an NP/PA student, in the same way a physician can use a medical student note. They are asking for comments about whether this should apply.
CMS also wants to continue lessening the documentation burden on clinicians. Read this next quotation carefully.
“Therefore, we propose to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the PFS.”
This seems like a radical change to me, and I present it without comment.
I’ll continue to update this article, as I work my way through the rule.