An overview of the proposed Medicare Physician Fee Schedule:
The proposed Medicare Physician Fee Schedule (MPFS) rule for 2020 was officially released on Aug. 14, 2019, encompassing various elements. Among these are proposals such as adjusting the PFS conversion factor to $36.09, introducing new HCPCS codes for bundled episode-of-care treatment for opioid use disorders, revising physician supervision requirements for physician assistants, and enabling the review and validation of clinical documentation by different medical team members like physicians, residents, nurses, students, and others. Notably, significant changes pertain to the documentation and compensation for evaluation and management (E&M) coding, particularly concerning new and established patient visits.
E&M services account for roughly 40 percent of allowed charges for PFS services, with office/outpatient E&M services making up nearly 20 percent of all allowed charges for professional services. However, considerable shifts have occurred since the MPFS Final Rule for 2019.
The American Medical Association (AMA) formed the AMA CPT® Workgroup on Evaluation and Management Coding to devise an alternative framework compared to the Centers for Medicare & Medicaid Services (CMS) structure outlined in the MPFS Final Rule for 2019. This workgroup’s efforts led to a set of recommendations officially adopted by the AMA in April 2019, scheduled for implementation in CPT starting Jan. 1, 2021. However, there’s more to this story. CMS has reviewed the AMA CPT Workgroup’s work and largely approved the changes, incorporating them into the 2020 Proposed Rule.
Here’s a summary of the proposed alterations to E&M codes for new and established patient visits, set to take effect on Jan. 1, 2021:
- Deletion of 99201 – This decision is based on the similarity between 99201 and 99202 in terms of straightforward medical decision-making.
- Removal of history and physical examination as factors for level-of-service selection – Providers will still need to document necessary history and physical examination details, but these elements won’t be considered when determining the service level.
- The level of service selection will hinge on medical decision-making or time. However, the proposed definition of time encompasses both face-to-face and non-face-to-face durations dedicated to various patient care activities, such as:Including activities such as:
- Reviewing test results to prepare for the patient’s visit
- Gathering or reviewing previously obtained medical history
- Conducting appropriate medical examinations or evaluations
- Providing counseling and education to the patient, family, or caregiver
- Issuing prescriptions, ordering tests, or arranging procedur
- Referring to and communicating with other healthcare professionals (if not reported separately)
- Recording clinical information in electronic or other health records
- Interpreting results independently (not reported separately) and communicating findings to the patient, family, or caregiver
- Coordinating care (not reported separately)
The proposed changes in Medical Decision-Making (MDM) resemble a restructuring of the three MDM sections, aligning them with the Risk Table format and presenting several noteworthy improvements:
Each distinct test, order, or document is individually counted. Rather than grouping multiple lab, radiology, or medical tests as one item, each unique test contributes to the overall volume, both in terms of review and ordering.
The decision regarding hospitalization is now recognized within the risk category. Definitions for the elements outlined in the revised MDM table have been introduced, enhancing clarity in understanding these components.
Maintaining differentiation in visits, there will be distinctions between levels 2-5 for new patient visits and levels 1-5 for established patient visits, each accompanied by its unique payment rate. This eliminates the previous minimal documentation parameters for level 2 and ensures specific payment rates for each level, removing the uniformity in payments across levels 2-4.
A new prolonged services code (99XXX) will exclusively apply to office/outpatient E&M visits. This time-based billing code will represent time beyond the highest E&M code in the set. To use 99XXX for a new office or outpatient hospital visit, the time spent must exceed the time requirement for 99205. This code will be applicable in 15-minute intervals and will be limited to use with CPT codes 99205 and 99215. The proposed wRVU for this code is 0.61.
The description of HCPCS code GPC1X will be modified to function as an add-on code, accounting for additional work and resource expenses related to ongoing care for singular, severe, or complex chronic conditions. However, ambiguity persists regarding the precise scope of these HCPCS codes. The proposed wRVU for this code is 0.33.
Proposals suggest an increase in work relative value units (RVUs) for over 75 percent of the nine remaining HCPCS codes in the sets of 99202-99205 and 99211-99215, while the remaining codes’ wRVUs will remain unchanged.Now is the time to review the proposed CMS changes and evaluate the work conducted by the AMA. There are ongoing tasks, so it’s crucial to provide feedback and comments on the proposed changes.