That’s final, and I mean it! | 2019 Physician Final Rule

The 2019 Physician Final Rule was released right on time on November 1, 2018. By now, you’ve heard the news that CMS is not implementing its major change to a single blended rate for E/M levels 2-5 in 2019. I won’t repeat what you’ve already read in detail other places, but here are the highlights, and my thoughts.

Things CMS didn’t do:

• CMS did not finalize multiple procedure payment reduction for modifier -25. The proposal was to pay at 50% the lowest valued procedure when two procedures were reported and modifier 25 was on the claim. CMS did not finalize this. Both will continue to be paid at the full allowance. CMS did comment that they believe that there is an overlap in paying for an E/M and some minor procedures, because some of the work overlaps. (Rooming the patient, reviewing the patient’s history, instructions for care) This is good news for many specialties.

• CMS did not finalize a proposal that would allow two visits by physicians of the same specialty in one calendar day.

• And they didn’t change the codes used by Podiatrists. Podiatrists will continue to use E/M codes.

Postponed until 2021

• CMS is not implementing a single payment and single RVU value for levels 2-5 E/M codes. They say they will implement a changed version in 2021, which would pay one fee for level one patients, one fee for levels 2-4 and one fee for level 5 visits. (Varied by new or established patients). They did note that the AMA is working on changes.

“A delayed implementation date for our documentation proposals would also allow the AMA time to develop changes to the CPT^® coding definitions and guidance prior to our implementation, such as changes to MDM or code definitions that we could then consider for adoption.” (page 633 of the rule)

So, although CMS says that these E/M changes are finalized, if the AMA can make changes CMS finds acceptable, it is possible these would not go into effect. The difficulty is getting all of the specialties to agree.

• The two add-on codes for primary care and selected specialty services. CMS has developed the code description for these, and valued them, but is not implementing these until 2021. The rule didn’t say how this would be funded, and keep in mind that these type of changes need to be budget neutral to CMS.  CMS had planned on using the savings from the reduced payments for modifier 25.  CMS did add specialties that could report the inherent complexity E/M code, and say that both the primary care and specialty  codes could be used on the same claim, if a primary care provider was addressing a complex, specialty diagnosis. Let’s not spend too much time on how this would work until closer to 2021. They changed the valuation of these two codes to be the same, rather than having a lower value for the primary care service.

• The new prolonged services HCPCS code (30 minutes) is postponed until 2021.

Finalized proposals

• There is a new CPT^® code for chronic care management performed by the physician, NP or PA, 99491, and CMS is making this a payable code. (Why are the care management codes so difficult to find in the CPT^® book, and why don’t I put a tab on them?)

• CMS is recognizing the four existing and two new inter-professional consultation codes, 99446-99452. These look like a nightmare to me to document and bill, and for not much money.

• Using HCPCS codes, CMS will pay for a brief, virtual check-in (G2012) and for the provider looking at a pre-recorded image or video, “store and forward” (G2010). The wRVUs are low. G2012 could be billed only by clinicians who have E/M in their scope of practice for established patient visits. It could not be a result of an office visit in the past 7 days or result in an office visit in the next 24 hours, or next available appointment. Does a phone call count? Here’s what the rule says.

“We are persuaded by the comments advising us not to be overly prescriptive about the technology that is used, and are finalizing allowing audio-only real-time telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. We note that telephone calls that involve only clinical staff could not be billed using HCPCS code G2012 since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.”(Page 111 of the rule)  

As for the pre-recorded picture or video (please, no cat videos) this is a service that is used to determine if an office visit is needed. If it results in an office visit, then it is considered bundled and may not be billed. It may not be billed if the patient was seen in the last 7 days. It is for established patients only.

Changes to E/M: changes to reduce redundancy and provider burden

• The billing provider does not have to personally document the chief complaint or the HPI. Ancillary staff may record this, or it could be recorded on a form by the patient. The billing provider can note that it was reviewed and verified.

• For established patients, the provider does not need to re-enter information already in the record, as long as it is noted as reviewed and unchanged, or reviewed and updated. The provider may choose to focus on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the required elements. The practitioner should still review prior data, update if needed and indicate that this was done.

• Removal of duplicative requirements for notations when services are furnished with a resident.

• For home visits, the medical necessity for the home visit does not need to be stated in the note.

That’s all for now. I’ll be writing about the new codes and requirements in article on the site, and will discuss them in our webinar on November 20.

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