General Surgery Coding Alert

Follow care-management modifications.

E/M coding and payment updates lead the charge of Medicare Physician Fee Schedule (MPFS) changes coming down the pike, but look for several other factors that could impact pay for your general surgery practice in 2020.

Perspective: CMS published the calendar year (CY) 2020 MPFS final rule in the Federal Register on Nov. 15, and it’s chock full of new codes, policy revisions, payment provisions, and more. The rulemaking offers several changes to modernize Medicare, as well as an update to the CY 2020 conversion factor.

Read on to learn final-rule updates you need to know for next year.

Focus 2020 Payment Expectations

The budget-neutral adjustment bumps the conversion factor up to $36.09, an increase of five cents from the CY 2019 amount of $36.04. Other changes in the rule are meant to “[free] up clinicians to focus on their patients rather than on paperwork,” says HHS Secretary Alex Azar in a press release for the final rule.

Pricing: MPFS “payments are based on the relative resources — relative value units [RVUs] — required to furnish services, with the conversion factor applied,” counsels attorney Elizabeth N. Swayne with King & Spalding LLP, in online analysis in the Health Headlines newsletter. “CMS also finalized technical improvements related to practice expenses and refinements to standard rates to reflect premium data involving malpractice expense and geographic practice cost indices.”

Little change: Don’t expect the small CF increase to provide much pay gain for your surgeons. Accounting for the CF increase and individual-code RVU changes, CMS estimates that the 2020 MPFS will result in no change in overall pay for general surgery practices.

Caveat: The actual payment impact for your specific practice could vary from that projection depending on the specific procedures and volumes you perform.

Prepare for Care Management Updates

A major change that could have a big impact on general surgery practices involves the creation of principal care management (PCM), which will begin on Jan. 1.

PCM describes care management services for one serious chronic condition, which you will be able to document using HCPCS codes G2064 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management … physician or other qualified health care professional …) and G2065 (… clinical staff).

Coding caution: Depending on the circumstances, the clinician overseeing the patient’s care may use the codes, but only one provider can bill for a specific condition. That might often leave surgeons out in the cold if their procedures are part of a larger treatment plan for a high-risk condition.

Experts point out some pros and cons of this new way to account for PCM. The new codes do fill “an apparent gap in coding related to care management, in that the existing chronic care management codes require a patient to have two or more chronic conditions, and there is no code for chronic care management of the patient with a single condition,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

However, “CMS should have [provided] either a definition of what a ‘high-risk disease’ truly is, or a list, so that practices would really understand when to use this type of code,” points out Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Further, “CMS would allow these codes to be reported for patients with multiple conditions when a particular physician was managing just one of them, which would move away from the continuous, comprehensive, and coordinated value-based care and primary care CMS has otherwise been encouraging as a cost-effective way to care for Medicaid patients,” says Moore.

Plus: CMS is also going to unbundle transitional care management (TCM) services with a number of other services and add some minor changes to the chronic care management (CCM) guidelines.

See the New ‘Sign and Date’ Policy Logistics

If administrative burdens bog down your practice workflow, then finalized changes to medical records’ documentation may streamline your daily grind.

“Clinician burnout is high because outdated government regulations are diverting their attention from what matters: patient care,” says CMS Administrator Seema Verma in a press release for the final rule.

To better align with that sentiment, CMS followed through and modified its documentation policy with a new “sign and date” update.

“CMS established a general principle to allow the physician, the physician assistant (PA) or the advanced practice registered nurse (APRN) who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team,” says Miranda Franco, senior policy advisor with Holland & Knight LLP in Washington D.C., in the Holland & Knight Healthcare Blog. “This principle would be applied across the spectrum of all Medicare-covered services paid under the MPFS.”

“Nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists” fall under the umbrella of APRN in the sign and date policy, too, according to the fact sheet.

Resource: Read the final rule at  www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other.