By now, you’ve read the headlines that CMS is proposing major changes to both the documentation requirements for new and established patient visits and the payment structure for the services.
I’ll try to go beyond the headlines in this post, and tell you what CMS is proposing.
Of course, we know that CMS puts together proposals every year for the payment policy for the coming year. Right now we are in a comment period for these policies. The final rule which will determine the actual policies for 2019 will be released at either the end of October or the beginning of November.
Changes to E/M services
New and established patient visit codes are responsible for 20% of the reimbursement under the Medicare physician fee schedule. Not 20% of all Medicare expenses, but of Medicare expenses paid under the physician fee schedule.
In the proposed rule, CMS describes their goal of decreasing administrative burden, and acknowledges the complexities and ambiguities of the current Documentation Guidelines. They propose significant changes to the requirements and along with that, paying for all visits reported with codes 99212—99215 with one payment, ($93) and all visits reported with codes 99202—99205 with a single payment as well. ($135).
And the winner is: medical decision-making
Medical groups could opt to continue to use the 1995 for the 1997 guidelines, or could select the visit solely based on the time of the visit, or, meet the medical decision-making requirements alone for a level 99212 visit. That level of medical decision-making, straightforward medical decision-making, would be all that is required to bill any level of office service.
CMS is proposing that one alternative for selecting a level of service would be the face-to-face time alone. This would not require that time is counseling time. However, CMS has not indicated and is seeking proposals about what time thresholds to use.
One alternative is to select one time threshold for all established visits and all new patient visits. One alternative is to use the CPT time definitions that we all know. But, they’re also asking for comments about whether to use the CPT time rule that states a unit of time is attained when the midpoint is passed.
CMS is proposing that these rules take effect January 1, 2019 but are asking for comments about whether to delay these changes for one year.
CMS is proposing to remove the requirement to document the medical necessity for a home visit.
Two visits in the same day
CMS notes that many physicians who are enrolled with Medicare in the same specialty actually perform as subspecialists. Currently, two visits to physicians of the same specialty in the same group practice cannot be paid on the same calendar date.
CMS is proposing to revise that to allow payment to Two physicians of the same specialty in the same group, when one is functioning as a different specialty, despite their enrollment.
New HCPCS codes
CMS is proposing an additional HCPCS code for prolonged services with a 30-minute duration.
CMS is proposing two new HCPCS codes to be used by podiatrists. One is for new patients and one is for established patient visits.
Primary care services
CMS is proposing a new HCPCS add-on code to be used in addition to an E/M visit for primary care services. The proposed definition is “Add-on code, List separately in addition to an established patient evaluation and management visit.”
New HCPCS code for complexity for selected specialties
CMS is proposing a new HCPCS add-on code to be used by certain specialists whose visits are inherently complex.
The definition of this code is proposed as “Add-on code, List separately in addition to an evaluation and management visit.” It is intended to be used by endocrinology, rheumatology, hematology/oncology, urology, neurology, OBGYN, allergy/ immunology, otolaryngology, cardiology, or interventional pain management. It seems to me they left infectious diseases off that list.
What are these HCPCS codes?
They haven’t been released yet. The codes in the proposed rule are dummy codes.
Reduction in payment for services when modifier 25 is used with a procedure with 0 global days
CMS is also proposing to decrease the payment when an E/M is reported with modifier 25 on the same day as a procedure with zero global days.
They are proposing a 50% payment reduction to the least expensive procedure or visit.
As I read that, the 50% reduction could be on the E/M service or on the procedure, depending on which was the least expensive. It is not clear to me from reading the rule if this includes procedures with a ten-day global period.
There’s more. As I work my way through the rule, I’ll be adding it to CodingIntel.
In the meantime, learn more by watching the on-demans webinar. Webinars are always free for CodingIntel members.
And remember, It’s just a proposal today.