Proposed Physician Fee Schedule Rule, 2024
CMS issued the Proposed Physician Fee Schedule (PFS) Rule July 13, 2023, with a 60-day comment period. We expect the Final Rule around the first of November, with effective dates for new coding policies 1-1-24. The rule includes implementation of policies mandated by Congress in the Consolidated Appropriations Act, 2023.
Some of these are significant changes, that CMS must implement. (This is literal; it is an Act of Congress.) The rule describes what telehealth flexibilities will remain in place until Dec. 31, 2024. There are new HCPCS codes proposed for caregiver training services, assessment of Social Determinants of Health, and principal illness navigation. (Keep in mind that all new CPT® and HCPCS codes in this rule are placeholder codes, not the actual codes.)
This article is an overview, with links to topics in more detail. Check back: I’m still reading and updating content.
I gave up editing the telehealth article and just started with a clean slate.
New professionals eligible to bill Medicare
CMS is adding benefit categories for Marriage and Family Therapists and Mental Health Counselors. Starting January 1, 2024, after they are enrolled, they will be eligible to provide services to Medicare patients. Of course, there are eligibility details that you can learn about here.
New benefit for Intensive Outpatient Program
CMS believes that there is unmet need for behavioral health services. They are proposing to allow hospitals, community mental health centers, FQHCs and RHCs to provide Intensive Outpatient Programs. This revises CMS’s partial hospitalization benefit (PHP) to provide outpatient services for a minimum of 9 hours/week (compared to 20 hours for PHP). Check back for details about this proposed program. Check back for details about this proposed program.
Updates for RHCs and FQHCs
CMS didn’t forget RHCs and FQHCs in their proposed rule. Many of the proposals duplicate the proposals for services paid under the PFS, and will be welcomed by those health care communities.
Check back! In the next week, I’ll be adding information about CMS proposals for caregiver training services, principal illness navigation, assessment of Social Determinants of Health, and Remote Physiological Monitoring
Split or shared services
CMS is proposing to continue its current policy for shared services. The substantive portion can be defined based on more than half of the total time or either one of the three key elements (history, exam or MDM). Since neither history nor exam are key components, this makes no sense to me. But, it provides flexibility for practices and will likely be included in the final rule in November.
Add-on complexity HCPCS code G2211
CMS is proposing to recognize and pay for HCPCS code G2211, an add-on code to E/M services for complexity. CMS wanted to implement this three years ago, but Congress postponed it until January 1, 2024. That article is updated here.
Congress halted implementation of payment for this service until Jan. 1, 2024 and CMS would like to proceed with it. It will benefit primary care and specialists who treat patients for a serious condition, whose needs require consistency and continuity of care over time. CMS wants to do this, and discusses it at length. There is opposition from some specialties because implementation of it will significantly factor into the budget neutrality provision, and lower RVUs for other services. This provision will garner many comments pro and con, and I have no idea what the outcome will be.
Adding HCPCS codes, recognizing CPT® codes
CMS is proposing paying for caregiver training (in a group) and principal illness navigation. The caregiver training services are existing and new CPT® codes. Principal illness navigation would be a HCPCS code. There is even a proposed HCPCS code for using an assessment tool for Social Determinants of Health. Before we get too excited, I’ll just say that the last service is given a work RVU of .18. (No one knows what these new codes will be! The rule uses placeholder codes. CPT® codes are released when the AMA ships the books and HCPCS codes when CMS releases the final rule. So don’t ask me what the final codes are, I’m waiting too.)
Caregiver Training Services (CTS)
CMS is proposing to recognize and pay for two existing, currently bundled CPT® codes and three new CPT® codes that will allow physicians and other qualified health care professionals to provide training for caregivers of patients.
One set of codes (96202, 96203) is for group training in behavior management/ modification of patients with a mental or physical health diagnosis. The group training would include caregivers of different patients. These existing codes had a status indicator of bundled and CMS is proposing to change that to active in 2024.
The other three codes are new for 2024. The codes in this article and the Proposed Rule are placeholder codes until CPT® releases the 2024 code set. Two of the codes, 9X015 and 9X016 are for caregivers of an individual patient to facilitate the patient’s functional performance in their home and community relating to Activities of Daily Living. (ADL) These are timed codes, 30 minutes and 15 minutes respectively. The third new code, 9X017 is for group training of multiple sets of caregivers (who are caring for different patients). That group training code is not assigned a time.
Principal Illness Navigation (PIN)
CMS is proposing two time-based HCPCS codes for the purpose of helping patients navigate their health care treatment for cancer and other high-risk, serious illnesses. “In the context of healthcare, it refers to providing individualized help to the patient (and caregiver, if applicable) to identify appropriate practitioners and providers for care needs and support, and access necessary care timely, especially when the landscape is complex and delaying care can be deadly.” p. 256. CMS believes this may be most important when a patient is first undergoing treatment.
CMS is proposing to pay for certified or trained auxiliary personnel under the direction of the billing practitioner. This may be a patient navigator or certified peer specialist as part of the treatment plan for a serious, high-risk disease which is expected to last at least three months.
Assessment code for Social Determinants of Health (SDoH)
CMS is proposing to establish a standalone G-code (HCPCS) for the assessment of SDoH. They define SDoH into broad groups: “economic stability, education access and quality, neighborhood and built environment, and social and community context, which include factors like how soon, food and nutrition access, and transportation needs.” p. 251-252. CodingIntel addressed the question of what conditions are included in SDoH in a recent Q&A.
Information about the Proposed Rule is updated each year when it is released. Previous years are archived below for reference.
Summary of the 2022 Proposed Physician Rule
Highlights of the 2022 Proposed Physician Fee Schedule rule
- Conversion factor decreases, sequester and PAYGO decreases still in place
- Telehealth updates, only behavioral health will be happy
- CMS proposals for shared services and critical care, no one will be happy
The first thing that many groups will want to know about the rule is what the conversion factor will be.
The conversion factor decreases by 3.75%, from $34.8931 to $33.6319.
But there are two other problems lurking for Medicare payments to medical practices. One is the resumption of the 2% decrease due to the sequester from a prior year. This was not in effect based on an act of Congress last year. Second, the PAYGO rule means that fees will decrease by 4%. The medical societies and specialty societies are lobbying Congress to stop those decreases. CMS includes in the rule their estimation of the impact by specialty, but this includes only the conversion factor and relative value unit changes, not sequester or PAYGO. Table 123 (pages 1180—1181).
The proposed rule was released July 13, 2021, and comments may be sent to CMS until September 13, 2021. We expect the final rule to be released in early November, although last year it wasn’t released until December 1st because of the public health emergency (PHE).
Every year, CMS accepts suggestions for CPT® codes that are potentially misvalued. This year, they discuss four codes and an additional series of codes that were submitted for consideration, However, for most of them they state they are not inclined to revalue the service. They are requesting comments as always, in the rule.
Everyone is interested in what is going to happen with telehealth. Prior to the public health emergency, CMS only paid for telehealth services to patients in underserved area when the patient went to certain locations such as a medical office or hospital to receive the service. This location was called the distant site. The clinician providing the service, at the originating site, billed for the professional fee. The distant site billed a small originating fee for the use of the space and the equipment.
CMS defined two categories of telehealth services, prior to the public health emergency. Category 1 are services that are similar to office visits, professional consultations and psychiatry. Category 2 services are services that are not similar to office visits, but are reviewed to determine if there would be demonstrated clinical benefit to the patient. During the public health emergency, they developed category 3 on a temporary basis. These services would need to meet the criteria for Category 1 or 2 in order to be permanently place on the telehealth list. This list is in Table 11 (pages 93-100 of the rule) Table 11 was slated to end at the end of 2021, or the end of the calendar year in which the PHE ended. CMS is now proposing to pay those services until December 31, 2023.
As for the telephone only codes, 99441–99443, CMS is not proposing to continue to pay for those codes after the public health emergency ends. They developed last year an additional telecommunication code G2252 for 11 to 20 minutes of virtual communications. This code is discussed below.
As for office visit codes, CMS believes that they do not have the statutory authority to continue to allow office visits via telehealth to be performed in areas all over the country not just in underserved areas, and from the patient’s home after the PHE ends. Payment for real-time, audio-visual office visit codes will end on the day that the PHE ends. When it ends is a determination by the Secretary of Health and Human Services.
Due to an act of Congress passed earlier, patients who are being treated for substance use disorder could receive telehealth services from their homes. CMS has reviewed the usage of telephone codes for behavioral health services. CMS is proposing to allow all behavioral health services to be performed through audio-visual communications, and in certain circumstances by telephone only. In order to bill these services the patient must have had an in person visit within the past six months. If telephone only services, the provider must have the capacity to provide real-time, audio-visual services, but is doing phone only because the patient is unable or unwilling to have two-way visual real-time communication.
Here is a quote from the rule.
“We are proposing to adopt a similar ongoing requirement that an in-person item or service must be furnished within 6 months of such a mental health telehealth service. We reiterate that our proposed policy to permit audio-only telehealth services is limited to services where the home is the originating site.”
CMS is proposing to allow this in RHCs and FQHCs, as well.
Prior to the public health emergency, direct supervision for incident to services required that the physician or practitioner who was supervising the incident to services was in the suite of offices where the services were being performed, immediately available to provide assistance. During a public health emergency, CMS allowed this to be done via real-time audio-visual communication. They are asking for comments and information about whether to continue to allow direct supervision to be provided via real-time audio-visual communication or whether to require that the supervising physician or practitioner be in the suite of offices, immediately available to provide assistance.
Brief communication code G2252
G2252 (Brief communication technology-based service, e.g., virtual check-in service, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11–20 minutes of medical discussion)
Last year, CMS developed G2252, brief virtual communication for 11-20 minutes of time. They developed in on an interim basis, and cross walked it to 99442, telephone only code. It follows the older HCPCS code G2012, for brief communication of 5-10 minutes. CMS is proposing to permanently adopt this code and payment.
New codes and Relative Value Units (RVU) values, updated RVU values
One of the functions of the proposed rule is to provide RVUs for new codes and for codes that need to be re-valued. In doing this, CMS excepts recommendations from the American Medical Association’s Resource-Based Relative Value Update Committee (RUC). CMS also does an independent assessment about the values. Table 13 of the rule, (pages 221-231), is 10 pages of codes that are either new codes for 2022 or existing code with proposals for reevaluation. The new codes are placeholder codes, not the real CPT® codes that will be in the CPT® book. However, looking at the table you can get an idea of where the new coding changes will be in your 2022 CPT book.
CPT® is proposing to add five remote therapy monitoring codes. These codes will be similar to remote physiological monitoring, but are for services that would be performed by a nurse or a physical therapist. Three have no profession valuation and two do.
CMS however notes that there is an issue with these codes because of their incident to rules.
“In our review of the new codes, we identified an issue that disallows physical therapists and other practitioners, who are not physicians or NPPs, to bill the RTM codes. By modeling the new RTM codes on the RPM codes, “incident to” services became part of the three direct practice expense-only (PE-only) codes (that is, CPT codes 989X1, 989X2, and 989X3) as well as the two professional work codes (that is, CPT codes 989X4 and 989X5). As a result, the RTM codes as constructed currently cannot be billed by, for example, physical therapists.”
There are currently two HCPCS codes for principal care management. CPT® has developed codes for those services, and two additional CPT® codes for principal care management. There are also new HCPCS codes for skin grafts.
The 2021 CPT® book added the concept of shared services, for E/M services provided jointly between a physician and other qualified health care professional. In May, CMS removed their manual sections for split/shared services, for critical care, and for skilled nursing services. They noted that they would address these issues in room making rule making, and they are doing so in this proposal rule.
CMS, which uses the term non-physician practitioners, allowed shared services in facility settings, inpatient, observation and ED. They allowed shared services in the office setting only if the service also met incident two rules. Shared services were not allowed in a nursing facility.
In their current proposals, they are proposing to continue to allow shared services in a facility, but adding rules related to that service. They are proposing to disallow using shared services in the office because in the office setting medical groups can use incident to services. They are proposing to allow groups to use shared services in a nursing facility. That is, if a medical practice bills using place of service 11, CMS would not allow shared services. If place of service 19 or 21, an outpatient clinic, shared services would be allowed. Shared services would still be allowed in inpatient and ED settings.
The fine print, however, is not going to make medical groups very happy. They are suggesting that in order to use shared services, the physician and non-physician practitioner must use time to select a code not medical decision-making and must bill the service under the clinician who has performed a substantive portion of the service. They are defining that as more than 50% of the service. Following CPT® rules, time jointly spent by the physician and non-physician practitioner in discussion or with a patient, could only be counted once not twice.
CMS is proposing to develop a modifier for when services are reported as split/shared.
Critical care services
CMS has always had a slightly different definition for critical care then CPT®. However, they are proposing to adopt the CPT® prefatory language, code descriptions, and parentheticals from the current CPT® book, pages 5-9 and 31-33. They are proposing to adopt CPT language that the time spent in separate procedures (not bundled into critical care) should not be included in critical care time. They are proposing to adopt CPT® language that 99291 should be used once per day by physicians in a group of the same specialty, which has been CMS’s policy as well. They note that CPT® does not address how to report when services go past midnight. For example, if a patient is admitted at 10:30 and critical care begins at 10:30 PM, and goes past midnight, should the clinician report the ad on code 99292 for the time spent after midnight, or should the clinician report an additional 99291 for the new calendar day.
On page 260 of the rule they say,
“In general, concurrent care is covered when the services of each practitioner are medically necessary, and not duplicative.”
This is so important for groups to remember. More than one specialty physician can provide critical care to one patient but there must be more than one medical condition that requires the expertise of each clinician. CMS affirms that they would continue to use the CPT® rule that the add-on code 99292 could be used by a same specialty partner who is continuing care on the same calendar day.
On page 261 they say:
“Under our current policy, the initial critical care service must be performed by a single physician or qualified NPP.”
Change is ahead: CMS is proposing to allow more than one practitioner to use their time within the same specialty to be added together to meet the requirement for 99291. After the cumulative time for 99291 is met, then a practitioner or covering practitioner could report 99292. CMS says CPT® code 99292 would not be reported by the practitioner or other practitioner in the same specialty and group unless an additional 30 minutes of critical care services are furnished to the same patient on the same day 114 total minutes. This is different than the current CPT® rule which uses the unit of time measurement and allows critical care add on codes to be used when the midpoint of 30 minutes has passed.
CMS notes that under their current policy, critical care may not be split/shared services between a physician and a non-physician practitioner. They say:
“…we believe it would be appropriate to revise our policy to allow critical care to be reported when furnished and split (or shared) services.”
They are proposing that critical care time provided by physician and a non-practitioner physician practitioner would be added together and that “the practitioner who furnishes the substantive portion of the cumulative critical care time would report the critical care services.”
They define a substantive portion of it as more than half of the cumulative time and require a modifier to be appended. They have not released the modifier that they intend to use.
If two or more practitioners spend time jointly meeting with a patient or discussing the care that may only be counted once for reporting purposes. CMS also says that they are concerned that adopting the CPT® rule that critical care and another E/M service could be done on the same calendar day might result in “unintended consequences for the Medicare program.” Of course, they did allow that in their prior manual. But for the upcoming year, “Thus, we are proposing that no other E/M service can be billed for the same patient on the same day as a critical care service when the services are free by the same practitioner, or by practitioners in the same group in the same specialty.”
As for documentation, CMS says the practitioners should document their total time but not necessarily start and stop times and should indicate the services that were performed including concurrent care or medically necessary.
There is bad news for surgeons in the rule, related to critical care in the post op period. Even as you’re reading this, the surgical specialists are getting their comments together to send to CMS. Because CMS doesn’t want to pay for critical care in the postop period. Currently Medicare will pay for critical care performed by a surgeon who performed the surgery with a 10 or 90 day global, if the critical care is unrelated to the anatomic site or the general surgery procedure that was performed. CMS is proposing to remove this exception that allows postop critical care to be done in the postop period for an unrelated condition.
Teaching physician rules
CMS is clarifying that if time is used to select an E/M code, only the time that the teaching physician was present could be counted, not resident time. This seems to me to be their current policy.
Regarding the primary care exception, during the public health emergency, residents billing under the primary care exception were permitted to use level 4 and 5 levels of service. CMS is proposing to end that after the PHE ends.
- Authorizes CMS to make payments directly to physician assistants
- Implements time rules for PT and OT assistant therapy services that pays at 85% rate for services performed by assistants. “Specifically, CMS is proposing to revise the de minimis policy to allow a timed service to be billed without the CQ/CO modifier in cases when a PTA/OTA participates in providing care to a patient with a physical therapist or occupational therapist (PT/OT), but the PT/OT meets the Medicare billing requirements for the timed service without the minutes furnished by the PTA/OTA by providing more than the 15-minute midpoint (also known as the 8-minute rule).”
- For colorectal screening tests that convert to diagnostic or therapeutic service, beneficiaries are currently charged 20%, rather than have the service covered in full as a screening. CMS is implementing a very slow, phased-in change in the percentage due, down to 0% in 2030.
- CMS is proposing that the penalty phase of the Appropriate Use Criteria (AUC) program for advanced imaging will not take effect until the later of January 1, 2023 or the January 1 that follows the declared end of the PHE.
- Will establish regulations for registered dieticians and nutrition professionals for nutrition therapy coverage and payment issues.
- Expand coverage for pulmonary rehab to patients who had COVID-19.
- Proposing a longer transition for Accountable Care Organizations (ACOs) reporting clinical quality measures for Merit-based Incentive Payment Systems. Proposing to freeze quality performance standards for 2023.
This proposed rule has implications for most medical practices. The policy changes related to shared/split services, telehealth and critical care are significant. We’ll have to wait and see what November brings.
2021 Proposed Rule
Summary of the 2021 Proposed Physician Fee Schedule Rule
- The rule was released August 3rd, and confirms CMS’s support of the AMA revised definitions of E/M codes 99202—99215, with increased RVUs and payment for these services
- Changes to payments in the fee schedule must be budget neutral; the increases in payments for codes 99202—99215 results in a significant decrease in to the overall conversion factor, setting up disagreement between specialties who perform procedures and those that perform mostly E/M services
- CMS is seeking comments regarding the definition of an add-on code GPC1X (placeholder code) to be added to E/M services for increase complexity
- CMS is thinking ahead about telehealth after the public health emergency (PHE) ends
- CMS notes that the final rule will be released by Dec. 1st, not Nov. 1st this year
The conversion factor decreases significantly from the current $36.09 to $32.26. The law requires budget neutrality in the physician fee schedule. That means, when new services are added or the fees for certain services increase, fees in other areas must decrease.
The increase in fees for 99202—99215 and decrease in the overall conversion factor means that some specialties will see an increase in their revenue in 2021, and some others will see a significant decrease. To see CMS’s estimate of the effect of these proposed changes download Table 90, page 898 and 899 of the proposed rule.
E/M services account for 40% of all allowed charges paid under Part B. The office and/other outpatient codes 99201—99215 account for 20% of allowed charges. The AMA is making substantial revisions to codes 99202—99215, the first ones in over two decades. In 2021, a clinician may select the level of service for these codes based on medical decision making or time. The definition of MDM is revised. If using time, the clinician will include total time for the day, including pre-time, visit time, and post-visit time. The codes now have a time range. CodingIntel members, you can read in detail about the upcoming changes here.
CMS is re-valuing certain services that include office and outpatient services, including monthly capitation for end staged renal disease, transitional care management and the maternity package. The maternity package is, in my opinion, valued too low and paid significantly too little, so this is welcome news.
Rules for all other E/M services that are based on history, exam and MDM remain unchanged in 2021.
Add-on code GPC1X
CMS will develop an add-on code for use with E/M services associated with primary care and some non-procedural specialty services. They discussed their intent to do this in 2021 in last year’s rule. They are actively seeking comments about how to define this add-on code and when it can be used.
For 2021, CPT is developing a new prolonged services code that may be added on to codes 99215 and 99205 only, when an additional 15 minutes of time is spent in either face-to-face or non-face-to-face services. Unfortunately, the time thresholds to use this code in the AMA’s 2021 draft guidelines (released last year) and the time thresholds in the CMS 2021 proposed rule are not the same. There will undoubtedly be many comments about this, but we will have to wait until the final rule is released to see if the time differences are resolved. CPT has not released the new prolonged services code yet, but is using placeholder code 99XXX now.
Members can watch the on-demand webinar to learn more about coding for prolonged services.
CMS responded to the PHE by removing restrictions on telehealth services, including geographic location of the patient and site of service restrictions. They substantially increased what services could be provided via telehealth, added physical therapists, occupation therapists and speech language pathologists to the list of providers who may provide telehealth, and temporarily added services that could be provided via audio/telephone only.
In the proposed rule, they are proposing to add nine services to the telehealth list permanently, and thirteen services temporarily. They are not proposing to include office visits in the list of services that can be provided via telehealth after the end of the public health emergency. They propose to stop paying for telephone codes 99441—99443 and 98966—98968 after the PHE ends. However, they are soliciting comments on adding additional virtual HCPCS services for services that take longer than G2012. (Tammy, should we link to our articles?)
Communication technology-based services (CTBS)
CMS is proposing to allow licensed clinical social workers, licensed psychologists, PTs, OTs and SLPs to use HCPCS codes G2061—G2063. These codes are for on-line messaging and management by clinicians who do not have E/M services in their scope of practice. They are also proposing to add to additional CTBS HCPCS codes for practitioners who cannot bill E/M services that correspond roughly to G2012 and G2010.
Remote physiological monitoring
CMS notes that they receive many questions about the correct use of codes 99453, 99454, 99091, 99457 and 99458. They are proposing some clarifications, including that codes 99453 and 99454 describes the work of non-practitioners, and these non-practitioners can be contracted, not employees, under physician/non-physician practitioner supervision. These two codes may only be reported once in a 30-day period, no matter how many devices are used. The data must be digitally, automatically uploaded, not patient recorded or self-reported. That is an important clarification.
All five codes listed above must be ordered only by physicians and non-physician practitioners who are eligible to bill E/M services.
CMS is proposing to make permanent the provision that consent can be obtained at the time the RPM service is obtained.
2020 Proposed Rule
- 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
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.
2019 Proposed Physician Fee Schedule Rule
Just a reminder that all of the new HCPCS and CPT® codes discussed in the rule are “dummy” codes, placeholders for the codes to be released.
In this post: podiatry, brief virtual check-in, inter-professional consultations, and more
Count your pennies
The conversion factor was changed from $35.9996 to $36.0463.
CMS is proposing two new codes to report Podiatry E/M services
- one for new patients
- one for established patients
The new patient visit would pay about $102 in the office and $73 in a facility setting. The established visit would pay $67 in the office and $45 in a facility setting. Podiatrists would use these codes in place of 99201—99215 codes.
Inherent complexity codes
- one for primary care
- one for certain specialist
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 (Add-on code, list separately in addition to an evaluation and management visit).
The wRVU for this service is .07. This code has differential payment based on setting, with a payment of about $5.40 in a non-facility, office setting and $3,96 in a facility setting.
GCG0X: Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology or interventional pain management-centered care (Add-on code, list separately in addition to an evaluation and management visit).
This add-on code has wRVUs of .25 and a payment of about $13.70, in a facility or non- facility setting.
New prolonged services code, 30 minutes
GPRO1: Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct pateint contact beyond the usual service; 30 minutes (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)
This code has wRVUs of 1.17. Payment in a non-facility would be about $67.40 and in a facility $63.80.
CMS heard that using the CPT® codes for prolonged services was difficult, because the prolonged time was 60 minutes. The time for this service is 30 additional minutes.
In order to bill it, the provider would need to meet the threshold of the base code and half of the prolonged code.
New CCM code (Chronic care management)
CPT® has developed a new code for 30 minutes in a calendar month of chronic care management performed by the physician or non-physician practitioner, not staff.
It has a work RVU of 1.22 and pays about $74.25. There is no differentiation between the facility and non-facility rate. The dummy code CMS used in the rule is 994X7, and we’ll see the CPT® code when the AMA releases the CPT® books.
There are existing CPT® codes for inter-professional consults, based on time, that had a status indicator of bundled. That is, CMS did not pay them. These codes, 99446—99449 have been in the CPT® book since 2013.
CMS is proposing to change the status indicator form bundled to active, making them paid services. Since these are existing CPT® codes, you can read about them in your current book.
99446 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional, 5-10 minutes
99447 11-20 minutes
99448 21-30 minutes
99449 over 31 minutes
CPT® has developed two additional codes in this series. (Below, are the dummy codes, new CPT® codes in your 2019 book when in arrives).
994X0 Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes
994X6 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 or more minutes of medical consultative time
Here are two quotes from the rule about the purpose of these services and CMS’s concerns:
“…specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician or other qualified healthcare professional…”
“We note there are program integrity concerns.”
The rule continues that we can’t bill for “professional courtesy or continuing education,” and that these services would require verbal consent from the beneficiary in advance of the service.
Acute stroke telehealth services
The Bipartisan Budget Act of 2018 required CMS to pay for acute stroke telehealth services. CMS is proposing to develop a modifier to report these services. The rule removes the restriction on geographic location for these services only.
Brief virtual check-in
There was a disturbance in the force. You felt it, didn’t you? CMS is proposing to pay for – well—here’s the (dummy HCPCS) code, read it for yourself.
GVCI1: Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
The non-facility payment would be about $15.40 and the facility payment would be $13.37. Not a lot of money, but isn’t there an expression about getting your nose under the tent?
This would only be allowed for established patients, and only providers with E/M services in their scope of practice could bill it. CMS is seeking comments about requiring verbal consent to bill and frequency limitations.
Here’s a picture of the tick | Remote Services
Haven’t you always wanted to send a picture of that rash or the tick to your provider? Or, have I been reading the rule for too long? Well, now we can do it.
CMS is going to pay your provider almost $13 to look at your picture and reply back to you “verbally.” There is a whopping .18 wRVU for this service, an office payment of about $12.97 and facility payment of $10.09.
GRAS1: Remote pre-recorded service via recorded video and/or images submitted by the patient (e.g, store and forward), including interpretation with verbal follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
There’s more to the rule, but these are some of the most interesting parts for medical practices.
Learn more about these and other important proposed changes by watching the on-demand webinar.