Gastroenterology Coding Alert

See the reason why CMS changed its mind on split/shared visits.

The Centers for Medicare & Medicaid Services (CMS) announced its final decisions regarding the Medicare Physician Fee Schedule (MPFS), and it looks like calendar year (CY) 2023 will be a mixed bag. Buckle up as we walk you through the changes to conversion factor (CF), colonoscopy screening coverage, and split/shared visits. Read on for insight into how it all could affect your practice this year.

Get Ready for an Even Lower CF

As you may remember, the proposed rule outlined a 4.4 percent CF decrease, and those who were hoping for CMS to make a change to the fee schedule got their wish… but not in the best way. The 2023 MPFS CF finalized an even bigger decrease than what was proposed.

For 2023, the final MPFS CF is $33.06, a decrease of 4.5 percent (or $1.55) from the CY 2022 MPFS conversion factor of $34.60, much to the dismay of experts in the healthcare industry. “We were hoping that CMS would finalize a smaller cut to the PFS conversion factor than the 4.4 percent reduction the agency proposed. Unfortunately, despite our comments, CMS wound up doing the exact opposite and finalized a slightly higher reduction,” the American College of Emergency Physicians (ACEP) warns. A decrease this significant could mean a decrease in overall revenue for gastroenterology practices.

Experience Expanded Coverage for Colon Cancer Screenings

CMS proposed two significant updates affecting Medicare coverage policies for colorectal cancer screenings and is finalizing those proposals for CY 2023. To align with recent United States Preventative Services Task Force (USPSTF) and professional society recommendations, CMS is reducing the minimum age for colorectal screenings from 50 to 45 years. It’s very possible that patients this age won’t be eligible for Medicare, but this change in minimum age will still have a positive impact on a wide range of patients.

“Medicare usually sets the precedent, so this would enable any Advantage plan, or other federal plan, to follow along with Medicare’s policy. It also would put pressure on any commercial payer to uphold USPSTF measures,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. Additionally, CMS is expanding the definition of colorectal screening tests to include a complete colorectal cancer screening. This means Medicare will now cover (as a preventive service) a follow-up screening colonoscopy after a non-invasive stool-based test returns a positive result, eliminating the beneficiary’s out-of-pocket expense for both tests.

Coding alert: As of now, ICD-10 has not formally instructed coders on how to sequence diagnosis codes in situations where a positive fecal test leads to a colonoscopy (which becomes therapeutic). “For the time being, add the ICD-10 code R19.5 [Other fecal abnormalities] as the third diagnosis below Z12.11 [Encounter for screening for malignant neoplasm of colon]. Also, code for the finding, such as K63.5 [Polyp of colon],” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. He also suggests watching how Medicare contractors and private payers process claims. “Patients should get no cost-sharing in this scenario,” he says.

Understand Split/Shared Visits

In the CY 2022 MPFS final rule, CMS finalized a phase-in approach to the split/ shared billing policy. During the one-year transition period, Medicare finalized that the provider who performed the substantive portion of the visit could bill under their national provider identifier (NPI). The agency also finalized the definition of the substantive portion of an evaluation and management (E/M) visit, except for critical care visits, as:

• CY 2022: The provider (physician or advanced practice practitioner (e.g., nurse practitioner)) who performed the patient history, physical examination, or medical decision making (MDM) — or — the provider who spent more than half of the total time rendering the service
• CY 2023: The provider who spends more than half of the total time rendering the service
• 2023 proposed rule: In the CY 2023 proposed rule, CMS noted they received “continued concerns about the implementation of [the] phased-in approach.” Reasons included concerns about using only more than half of the total time to identify the substantive portion as well as requests to recognize MDM by itself as the substantive portion.

Consequently, instead of requiring providers to use the substantive portion definition of only “more than half of the total time” on Jan. 1, 2023, CMS proposed to delay the policy implementation until CY 2024 and maintain its 2022 approach through 2023.

CMS finalized that approach in the 2023 final rule: Thus, clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or MDM — or more than half of the total practitioner time spent to define the substantive portion — instead of only using total time to determine the substantive portion.

CMS lists two reasons to explain and defend their change of heart:

1) 2023 E/M updates: Effective Jan. 1, 2023, several E/M codes are updated to fall in line with the 2021 E/M changes to coding for office and other outpatient services. Examples of these codes include 99221-99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination …) and 99281-99285 (Emergency department visit for the evaluation and management of a patient …). Delaying the split/shared visit policy implementation until 2024 gives providers a transition year to get acclimated to the 2023 E/M guidelines and get their practices up to speed on the incoming changes.

2) Feedback: The delay allows CMS to gather more comments and feedback from interested stakeholders regarding the policy and how it could be altered or further refined.

Additionally, in a March 2022 letter to CMS administrator Chiquita Brooks-LaSure, several medical organizations, including the American Medical Association, strongly urged CMS to discontinue its split/shared visits policy and not move forward with the transition set to take effect in 2023. The organizations felt the policy wouldn’t allow providers to effectively co-manage patients’ needs and was contrary to clinical alignment (https://searchlf.ama-assn.org/letter/documentDownload?uri=/unstructured/binary/letter/LETTERS/Sign-on-letter-to-CMS-re-Split-or-Shared-Visits-Final-03-29-22.pdf).

For a fact sheet on the CY 2023 Physician Fee Schedule final rule, visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule.