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PFS Final Rule for 2020

Coding


PFS Final Rule for 2020

Date Posted: Thursday, January 09, 2020

 

As the Final Rule was released earlier this month, we have updated our summary to include most anticipated topics for the upcoming years. These policies will go into effect January 1, 2020, except for the evaluation and management changes scheduled for 2021. Should you require additional details or contact information for CMS, we encourage you to visit the full document at https://federalregister.gov/d/2019-24086.

2020 Conversion Factor - $36.09 (up from 2019 at $36.04) 

Evaluation & Management Services
The new and established evaluation and management (E/M) CPT codes continue to take another shape as expected. In the previous payment model for 2021, CMS was ready to collapse levels 2-4 to a flat rate and introduce two new G codes, increasing payment for specialty complexity (per-visit resources), and time. Public commenters and stakeholders both felt this methodology was still overly complicated and not solving the problem of lessening the burden of coding and documentation. The intent of the code set was revisited and yet another new method has been introduced and will further revise as below.

Final CY 2021 total time and RUC recommended work RVU

Changes for 2020:
  • 99201 will be deleted from the new patient code set.
  • Levels of service time increments and RVU values will change based on RUC recommendations (see table below).
  • Elimination of history and exam as a factor in the level of service for new and established E/M codes (this is still unclear if this will span into other E/M categories beyond 99211-99205).
  • Providers will have a choice of using time or medical decision to select a given level of service.
  • A new prolonged code will be introduced, 99XXX (increments of 15 minutes) for time over and above the maximum code (99205 & 99215) for additional effort both face-to-face and non-face-to-face time (.61 work RVU).
  • Revision of HCPCS code GPC1X for visit complexity will now cover both primary care and specialty services. This has been revised as “visit complexity inherent to evaluation and management associated with medical care services that serve as the continual focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient's single, serious, or complex chronic condition”. Terms within this definition will likely gain more clarity in the 2021 final rule.

Telehealth & Virtual E-Visits
CMS finalized new HCPCS codes to temporarily house the new opioid disorder management code sets. These will expand the access for patients whether visits take place in the office or through telehealth. Note that these services require face-to-face interaction and can be delivered by individuals who are qualified to provide the services under state law and within their scope of practice “incident to” the services of the billing physician or other practitioner, as per CMS. 

Three new codes will be valid for 2020:
  • G2086 - Office-based treatment for opioid use disorder, including the development of the treatment plan, care coordination, individual therapy, and group therapy, and counseling; at least 70 minutes in the first calendar month. (7.06 work RVU)
  • G2087 - Office-based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy, and counseling; at least 60 minutes in a subsequent calendar month. (6.89 work RVU)
  • G2088 - Office-based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy, and counseling; each additional 30 minutes beyond the first 120 minutes (List separately in addition to code for primary procedure). (Add on code - .82 work RVU)

Three new CPT codes will available for 2020 to use for e-visits. These are patient initiated digital communication visits and can be billed by a physicians or qualified healthcare practitioner. CPT code definitions will enforce the 7-day rule (not relating to a previous or leading to a follow-up evaluation and management visit). The codes require permanent documentation storage in an EMR or similar type record. These cannot be combined with other virtual check-in visits and do require a waiver to notify patients of their cost-sharing portion. CMS announced blanket waivers for virtual and e-visits are acceptable for a period of one year.

New Codes:
  • 99421 - On-line digital E/M service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes (.25 RVU)
  • 99422 - On-line digital E/M service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes (.50 RVU)
  • 99423 - On-line digital E/M service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21+ minutes (.80 RVU)

Supervision for PA's
CMS finalized the regulation that Physician Assistant (PA) supervision will now be governed and in accordance with State Law as opposed to current Federal standards. In absence of a State Law, CMS rules would apply and requiring that the supervision be evidenced by documentation in the medical record as to the relationship of the PA working with the physician. The revision will allow states to tailor and control the use and supervision of PA services. Although public comment pushed back on CMS standards and documentation requirements, the final rule did clarify that the supervision relationship is evident by documenting at the practice level (scope of practice and working relationship), as opposed to the individual medical record. This would apply to all types of services within the scope of State Law, specialty, and practice.

Student Documentation
CMS has finalized the rules around defining 'student' and how this applies to usable documentation within the medical record. The revision includes PA, NP, CNS, CNM, CRNA, and APRN along with medical students who may document and contribute to the billable portion of the attending's or supervising provider's progress note. Rather than re-documenting, the billing provider can review and verify (sign & date) the documentation as part of the final note. This revision is intended to reduce the amount of documentation presently required under current guidelines.

Transitional Care Management (TCM)
Good news for providers using TCM codes. CMS finalized not only an RVU increase for TCM services; they also approved unbundling 17 services (see table below) that might be performed during these episodes of care. As part an outside evaluation, CMS concluded transitional care codes were both underutilized likely due to the administrative burden in documenting and undervalued. The table below represents the codes being unbundled starting 2020. The RVU value will increase - CPT code 99495, moderate complex to 2.36 and 99495 high TMC 3.10. Definitions of the CPT codes are set to remain the same.

  • TCM 99495 - services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit within 14 calendar days of discharge. 
  • TCM 99496 - with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least high complexity during the service period; face-to-face visit within 7 calendar days of discharge.

TCM - Services Unbundled for 2020

Chronic Care Management (CCM)
CMS has monitored the use of these codes and determined that utilization has reached about 75% of what they anticipated under the PFS. For the upcoming year, they are finalizing only one new G code G2058 to account for chronic care management clinical staff time, each additional 20 minutes (work RVU .54). This code will be capped for use, only two times per service period, per beneficiary.

CMS will not be adding the proposed G codes to redefine Complex Chronic Care Management. CPT 99487 will still be defined as - Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by physician or other qualified healthcare professional, per calendar month. Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not reported separately - (1.0 work RVU). The new add-on code would be as 99489 - each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (List separately in addition to code for primary procedure) (.50 work RVU).

A further revision defining a typical care plan was also approved to eliminate redundant language. CMS is also clarifying the fine print, that the elements of the care plan are suggested and not always required and would be at the discretion of the provider and specific to the needs of the patient.

The comprehensive care plan for all health issues typically includes, but not limited to:
  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Cognitive and functional assessment
  • Symptom management
  • Planned interventions
  • Medical management
  • Environmental evaluation
  • Caregiver assessment
  • Interaction and coordination with outside resources and practitioners and providers
  • Requirement for periodic review
  • When applicable, revision of the care plan

Principal Care Management
A new subset of the CCM codes will be implemented for 2020 providing coverage for managing one chronic illness (vs. multiple) by specialists. These codes can be used during the same episode of care as primary care (managing multiple chronic problems). 

Principal Care Management codes are defined as, G2064 at least 30 minutes of physician or other qualified healthcare 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 - (1.45 work RVU).

HCPCS code G2065 would cover clinical staff time yet without the option of add-on time like the other CCM codes. Code definition is proposed to read - 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 healthcare 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 - (.61 work RVU).

Emergency Room Services
Although there were multiple CPT sections revised for 2020, Emergency Room E/M's work values are set to increase for 2020 (CPT Codes 99281, 99282, 99283, 99284, and 99285). Based on the CY 2018 PFS final rule, CMS determined these codes might not be appropriately valued based on the full resources involved with patient care. For CY 2020, CMS has finalized the RUC recommended work RVUs of 0.48 for CPT code 99281, a work RVU of 0.93 for CPT code 99282, a work RVU of 1.42 for 99283, a work RVU of 2.60 for 99284, and a work RVU of 3.80 for CPT code 99285. CMS will not be making a recommendation to increase the practice expense related to these five codes.

Jana Weis, BA, Dip Com, CPC is the Principal at Gill Compliance Solutions based in the Northwest.
Jana is a renowned compliance coding professional with a bent for ingenuity and innovation. Her pursuit of leading technological health care solutions in addition to her 20+ years of experience in medical coding and compliance led her to form Gill Compliance Solutions (GCS) in 2010.  Her expertise in health care consulting leads physicians and hospitals, regionally and nationally, through the complex world of compliance to accurately report and monitor coding compliance practices. www.gillcompliance.com 

GCS will be offering tailored E/M training through 2020. This includes the use and workflow of telehealth and virtual services. If you are looking to schedule education for your providers, residents, coders, or billing staff, please contact Jana Weis at jana.gill@gillcompliance.com. Training will be offered both virtually and on-site.



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