Gastroenterology Coding Alert

Hint: Proposal would cause one practice in our sampling to lose $25,000 in a year.

If your practice often complains about the limitations that the 1995 and 1997 E/M guidelines place on E/M coding, CMS may have delivered a gift in the form of the latest fee schedule proposal. The agency is considering major changes to how E/M codes are documented, billed, and paid, which could cause major changes to your systems if the agency finalizes these changes.

Here’s the scoop: CMS released its proposed Medicare Physician Fee Schedule (MPFS) for 2019 on July 12, and it includes what the agency is calling “historic” E/M documentation changes to the outpatient office visit codes (99201-99215). Those changes include the following:

• Use medical decision-making or time for outpatient E/M versus the current guidelines.
• Give physicians the option of using time as a factor even if counseling or care coordination don’t dominate the time of the encounter.
• Put re-documenting aside and let providers “focus their documentation on what has changed since the last visit or on pertinent items that have not changed.”
• Give practitioners the option of accepting data plugged in by staff or patient instead of timely re-entering.

In tandem with these documentation and code selection changes, CMS is proposing a “new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services,” the agency said in a Fact Sheet about the change. The payment levels are proposed as follows:

• 99212-99215: $93 for each of these codes
• 99202-99205: $135 for each of these codes.

This would mean that payments for level five codes would go down, while pay for level two codes would go up. Practices that report a lot of level five codes would be likely to lose money, but some practices would see gains, says Cyndee Weston, CPC, CMC, CMRS, executive director of the American Medical Billing Association (AMBA) in Davis, Oklahoma.

Check Out These 3 GI-Specific Examples of How Pay Could Change

To determine the impact that this change might have on gastroenterology practices, Gastroenterology Coding Alert reviewed the utilization data for three different GI practices and calculated how it would impact each of them.

These calculations assume that the gastroenterologists will earn $93 for each of the following codes under the proposal, and that they currently bring in the following average reimbursement for 99212-99215:

• 99212: $45
• 99213: $75
• 99214: $109
• 99215: $148

Impact to Practice 1: Gastroenterologist in Southern California:

• 99212: Billed 92 times in one year – worth $4,140 today, worth $8,556 under proposal
• 99213: Billed 302 times in one year – worth $22,650 today, worth $28,086 under proposal
• 99214: Billed 311 times in one year – worth $33,899 today, worth $28,923 under proposal
• 99215: Billed 84 times in one year – worth $12,432 today, worth $7,812 under proposal

Total Difference: This physician earned $73,121 for these four codes under today’s payment structure, and would earn $73,377 under the proposal. This physician would see $256 more pay under the proposal for these four codes.

Impact to Practice 2: Gastroenterologist in South Florida:

• 99212: Billed 27 times in one year – worth $1,215 today, worth $2,511 under proposal
• 99213: Billed 170 times in one year – worth $12,750 today, worth $15,810 under proposal
• 99214: Billed 1,228 times in one year – worth $133,852 today, worth $114,204 under proposal
• 99215: Billed 187 times in one year – worth $27,676 today, worth $17,391 under proposal

Total Difference: This gastroenterologist earned $175,493 for these four codes under today’s payment structure, and would earn $149,916 under the proposal. This doctor would see $25,577 less pay under the proposal for these four codes.

Impact to Practice 3: Gastroenterologist in Central Arizona:

• 99212: Billed 62 times in one year – worth $2,790 today, worth $5,766 under proposal
• 99213: Billed 321 times in one year – worth $24,075 today, worth $29,853 under proposal
• 99214: Billed 644 times in one year – worth $70,196 today, worth $59,892 under proposal
• 99215: Billed 66 times in one year – worth $9,768 today, worth $6,138 under proposal

Total Difference: This physician earned $106,829 for these four codes under today’s payment structure, and would earn $101,649 under the proposal. This gastroenterologist would see $5,180 less pay under the proposal for these four codes.

Bottom line: Two of these three physicians would lose money under the proposal versus what they earn now. Of course, this doesn’t mean your gastroenterologist will also face the same fate under the proposal, but it does suggest that GI practices should keep a close eye on the proposed changes. If you know how frequently you reported each of these codes, you can perform a similar calculation to determine how the change would affect you.

“Keep in mind also that with simplified documentation requirements, some practices might be able to see more patients,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “The intention of CMS is for this change to be budget neutral overall.

Would Documentation Guidelines Hurt You?

Keep in mind that if the proposal is finalized, you would have to be ready to code your charts based on new criteria. For instance, if the code level ends up being based on medical decision-making (MDM) rather than the current method of history, medical decision-making, and exam, there could be a learning curve for some practices, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national coding and billing company based in Bedford Massachusetts. “MDM can be subjective – the risk table is not black and white unless you’re using the intervention column, which is probably historically the least relevant.”

Certainly, the inclusion of a suggested E/M change in the fee schedule proposal doesn’t mean that a change will actually happen. Keep an eye on Gastroenterology Coding Alert for all the latest on whether CMS moves toward finalizing these proposals.

Resource: For a closer look at the MPFS proposed rule for CY 2019, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf.