Coding Roundtable

Educational webinars available for purchase can be accessed here.

Watch for upcoming webinars –

September 2020:  2021 ICD-10 Update

December, 2020:  2021 CPT Update

 

Coronavirus Information

Links to CMS guidance on Coronavirus. Please refer to private payer policies for their guidance on coding and billing of Coronavirus.

A. Coronavirus:

  • Medicare Coverage and payment of virtual services—03/17/2020 publication

Medicare provides coverage for telehealth under certain conditions, some of which are temporarily different during the COVID-19 pandemic.
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

B. Coronavirus-Telehealth Services

Coronavirus-covered Telehealth Services – Updated 04/30/2020 can be found at:
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

C. Public Health Emergency exceptions – Teaching Physicians and Residents: Expansion of CPT Codes that May Be Billed with the GE Modifier

Teaching physicians and residents: Expansion of CPT codes that may be billed with the GE modifier under 42 CFR 415.174 on and after March 1, 2020, for the duration of the public health emergency:

  • Residents furnishing services at primary care centers may provide an expanded set of services to beneficiaries, including levels 4-5 of an office/outpatient Evaluation and Management (E/M) visit, telephone E/M, care management, and some communication technology-based services
  • This expanded set of services are CPT codes 99204-99205, 99214-99215, 99495-99496, 99421-99423, 99452, and 99441-99443 and HCPCS codes G2010 and G2012
  • Teaching physicians may submit claims for these services furnished by residents in the absence of a teaching physician using the GE modifier

Medicare Administrative Contractors will automatically reprocess claims billed with the GE modifier on or after March 1, 2020, that were denied. You do not need to do anything.

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-07-09-mlnc  

D. Popular sites recommended to be bookmarked:

Current Emergencies-
Webpage:  https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
Partner Toolkit:   https://www.cms.gov/outreach-education/partner-resources/coronavirus-covid-19-partner-toolkit

E/M CHANGES IN 2021

The American Medical Association has provided several modules that explains the Office E/M CPT Code revisions in 2021.  The modules are found at https://www.ama-assn.org/practice-management/cpt/implementing-cpt-evaluation-and-management-em-revisions.

 The American Medical Association has also provided guidance on the selection of the new Office E/M CPT codes effective 01/01/2021: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. 

  • E/M Introductory Guidelines related to Office or Other Outpatient Codes 99202-99215
  • Revised Office or Other Outpatient E/M codes 99202-99215. For the complete version of E/M Introductory guideline changes, Office or Other Outpatient (99202-99215) code changes, Prolonged Services code (99354, 99355, 99356, 99XXX) and guideline changes, see Complete E-M Guideline and Code Changes.doc.   Note: this content will not be included in the CPT 2020 code set release

Highlights:

  • 99210 will be deleted effective Jan 1, 2021. The code revisions impact selection of CPT codes 99202-99215.
  • Beginning with CPT 2021 and except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215).
  • 2021-AMA will be including rules about shared or split services and time in the CPT book.
  • History and Exam- Codes 99202-99215 may be selected based on time or medical decision making.
    • CPT book will state: “Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified health care professional reporting the service.”
  • Calculating the level of medical decision making to select a code is also revised for 2021.

  • New Prolonged Service Code 99471 will be utilized with 99205 and 99215.  Additional information on 99417 can be found at:
    https://pbn.decisionhealth.com/Blogs/Detail.aspx?id=200922

Refer to the Medical Decision Making graph: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

2021 Medicare Physician Fee Schedule and Quality Payment Program proposed rule

CMS released the 2021 Medicare Physician Fee Schedule (PFS) and Quality Payment Program proposed rule on August 4. The rule would make permanent certain telehealth and workforce flexibilities provided during the public health emergency, establish payment rates for physicians and other health care professionals for 2021, and make significant changes to the Quality Payment Program.  Comments are due October 5, 2020.

Below are highlights of some of the proposals in the rule:

Physician Fee Schedule Highlights

  • Includes evaluation and management (E/M) documentation and payment changes finalized in the 2020 PFS rule, which would increase payment for E/M services in 2021;
  • Lowers the conversion factor significantly to account for the increases in payment for E/M and other services, from $36.09 to $32.26, a decrease of approximately 11%;
  • Expands coverage for telehealth services by:
    • Proposing to add services to telehealth list on Category 1 basis for services that are similar to those already on the list. This includes the newly established E/M visit complexity code and prolonged services code, among others.
    • Proposing to create a third temporary category of services added to the Medicare telehealth list during the COVID-19 public health emergency (PHE) that would remain on this list through the calendar year in which the PHE ends. These additions include home visits, emergency department visits, and psychological testing, among others.
    • Seeking feedback on services that were added to the Medicare telehealth list temporarily during the PHE that CMS is not proposing to add to the list after the PHE ends.
  • Solicits feedback on waivers and flexibilities in effect during the public health emergency that should be made permanent, including the supervision of residents by a teaching physician via real-time audio and video technology;
  • Proposes to allow direct supervision to be provided using real-time, interactive audio and video technology through December 31, 2021. Seeks comment on guardrails and whether this should be considered beyond 2021;
  • Proposes changes to the Medicare Shared Savings Program (MSSP) for performance year 2020, to provide automatic full credit for CAHPS patient experience of care surveys. Seeks comment on an alternative scoring methodology approach under the extreme and uncontrollable circumstances policy for performance year 2020.

Quality Payment Program Highlights

  • Proposes the following changes to the performance threshold and category weights for the 2021 performance year (2023 payment year):
    • Performance threshold: 50 points (decrease from 60 points finalized in CY 2020 PFS final rule)
    • Quality performance category weighted at 40% (decrease from 45% in PY 2020)
    • Cost performance category weighted at 20% (increase from 15% in PY 2020)
    • Promoting Interoperability performance category weighted at 25% (no changes from PY 2020)
    • Improvement Activities performance category weighted at 15% (no change from PY 2020)

**By statute, the Cost and Quality performance categories must be equally weighted at 30% beginning in 2022 performance period.

  • States that in light of the COVID-19 PHE, CMS will not be introducing any MIPS Value Pathways (as finalized in 2020 final rule) for the 2021 performance period. CMS will be proposing additions to the MVP framework:
    • Subgroup reporting option
    • A fifth principle of MVP to promote digital performance measure submission
  • Establishes a new APM Performance Pathway (APP) reporting option for 2021 to align with the new MVP framework. This would be only available to participants in MIPS APMs, and reported by the individual eligible clinician, group (TIN), or APM entity;
  • Proposes to sunset the CMS Web Interface as a collection type beginning in the 2021 performance period;
  • Ends the APM Scoring Standard beginning with the 2021 performance period, and adds the APM entity as a submitted type which may report to MIPS on behalf of MIPS-eligible clinicians.

CMS released a PFS fact sheet and a QPP fact sheet, along with the proposed rule. For questions or additional information, please contact Gayle Lee or Kate Ogden. 

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