EM Coding Alert

E/M fees could go up or down, while prolonged services coding could get sticky.

You probably won’t be surprised to know that E/M services feature prominently in the Centers for Medicare & Medicaid Services’ (CMS’) proposed Physician Fee Schedule (PFS) for 2021.

We won’t know until the end of the year whether any, some, or all of these proposals will become reality in 2021. But it’s still a good idea to take a closer look at what CMS has in mind and how it could affect your E/M coding next year.

Payment Increases Planned for Some E/Ms, Immunization Administrations …

Many of your most-used E/M codes are earmarked for rate increases this year. Office and outpatient E/Ms, for example, could well be going up, with some hefty increases slated for established patient visits:

On average, “E/M RVUs [relative value units] are going up around 20 percent,” notes Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC. In addition, “CMS is also extending the increase in office/ outpatient E/M values to other services, including cognitive assessment and care plan services [99483] and transitional care management services [99495-99496],” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

… While CF May Be Going Down

Meanwhile, the proposal calls for “the conversion factor [CF] to go down by about 11 percent,” Blanchard notes. “Based on what we know so far, if the conversion factor ultimately remains unchanged — as often happens — we estimate that on average there would be a 25 percent increase in established patient E/M charges. If the conversion factor does change, the effect is closer to single digits,” Blanchard continues.

As a reminder: The CF is the final multiplier in the complex CMS payment formula known as the resource-based relative value scale (RBRVS), where the three RVU elements involved in providing services and procedures — work (W), practice expense (PE) and malpractice insurance (MP) — are all multiplied by geographic practice cost indices (GPCI), added together, then multiplied by the CF to produce a dollar value for those services and procedures.

This part of the proposed rule will be hotly contested by many medical associations and organizations, including the American Medical Association (AMA), as they believe such a large reduction will be devastating to healthcare providers while the COVID-19 public health emergency (PHE) is having such a negative impact on the economy. (You can view the AMA’s position by going to: https://www.ama-assn.org/practice-management/medicare/cutting-medicare-pay-during-covid-19-pandemic-doesn-t-make-sense.)

Telehealth Expansion Continues Apace …

The explosion in telehealth usage during the PHE has also inspired CMS to propose adding 99XXX (Prolonged office or other outpatient evaluation and management service(s) …; each additional 15 minutes …), 99483 (Assessment of and care planning for a patient with cognitive impairment …), 99334-99335 (Domiciliary or rest home visit for the evaluation and management of an established patient …), and 99347-99348 (Home visit for the evaluation and management of an established patient …) to the current telehealth list. Additionally, it is also seeking comments about adding other codes, either on a temporary or permanent basis.

… While the Prolonged Service Proposal is Perplexing

Code 99XXX, which CPT^® will designate as +99417 in 2021, also features in another, more confusing CMS proposal for next year.

“CMS is proposing to only permit 99XXX when the maximum time of 99205 or 99215 has been exceeded by 15 minutes,” explains Moore. This is not the same as CPT^®’s instructions for +99417 that tell you to add the code on to 99205 or 99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) when these codes hit the maximum in their time ranges. So, for example, CPT^® tells you to add a unit of +99417 when the total duration of the new patient visit hits 75 minutes or when the total duration of the established patient visit hits 55 minutes. CMS, on the other hand, would have you add the code onto 99205 when the time for the new patient visit hits 89 minutes or onto 99215 when the time for the established patient hits 69 minutes.

This means that “if CMS finalizes the proposal, physicians and coders will need to be aware that the CMS rules will differ from the CPT^® rules,” explains Moore.

For a fact sheet on the CY 2021 Physician Fee Schedule proposed rule, visit: https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4. To view the full CY 2021 Physician Fee Schedule and Quality Payment Program proposed rule, visit: https://www.cms.gov/files/document/cms-1734-p-pdf.pdf. And to comment on the proposed rule, follow the instructions found at: https://beta.regulations.gov/document/CMS-2020-0088-1604 and submit your comment before 5 PM on Oct. 5, 2020.