General Surgery Coding Alert

There’s more to know than E/M.

In General Surgery Coding Alert Vol. 23, No. 2, you read that the Consolidated Appropriations Act of 2021 (CAA) buffered the blow to Medicare Physician Fee Schedule (MPFS) payment by reversing part of the conversion factor (CF) decrease.

Now we have more to report about how the MPFS and CAA might impact your general surgery practice in other important ways. Let our experts show you what you need to know so your surgeons can comply with new coding, procedure, and payment rules.

Eliminate G2211 for Extra E/M Pay

If you were scrambling to implement G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)), you can breathe a sigh of relief, because the code will no longer influence your E/M coding for 2021 and beyond.

Here’s why: The CAA has placed a moratorium on payment for the newly introduced add-on code G2211. “Congress called for a three-year delay (until at least 2024) in prohibiting Centers for Medicare & Medicaid Services (CMS) from making payments for G2211 or any similar code,” says Linda Vargas, CPC, CPMA, CPCO, CPC-I, CEMC, CCC, CGSC, coding manager at Truman Medical Centers in Kansas City, Missouri. “As discussed in the relief bill, part of the justification for delaying G2211 is that it will actually help pay for a 3.75 percent increase to offset the previous CF cut,” Vargas explains.

G2211 problems: CMS introduced code G2211 in the final rule by stating: “the time, intensity, and physical effort (PE) involved in furnishing services to patients on an ongoing basis that result in a comprehensive, longitudinal, and continuous relationship with the patient and involves delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape, are not adequately described by the revised office/outpatient E/M visit code set.”

That’s where G2211 was supposed to come into play. The idea was that, for applicable E/M services, you would include code G2211 alongside the respective new or established patient office/outpatient visit code. While CMS used nearly 12 pages in the MPFS final rule to convey their point, when and how to use G2211 remained murky at best.

See NPP Rule Changes

Although the overwhelming focus for the MPFS final rule changes has been on 2021 E/M, “there are many other important changes that require careful review and preparation for any coding professional,” says Chelsea Kemp, RHIT, CCS, COC, CDEO, CRC, CEDC, CGIC, HIM coding specialist at Dignity Health Yavapai Regional Medical Center in Prescott, Ariz.

For instance: General surgery practices should take note of the revised rules on diagnostic testing and medical record review designed to give non-physician practitioners (NPPs) an expanded level of access and control.

Under the MPFS regulation at §410.32(b)(1), CMS has amended the guidelines on diagnostic supervision to allow certain NPPs to perform diagnostic supervision services without a “general level of physician supervision.” In other words, NPPs are now eligible to perform and bill for specific qualifying diagnostic services without a physician present. Previously NPPs were allowed to order diagnostic tests, but only the patient’s physician could supervise the diagnostic testing.

“In place of supervision exclusively by the physician, a qualified NPP (typically a physician assistant) can now supervise diagnostic tests that are performed by a nurse or medical technician,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. “Keep in mind that the NPP won’t be supervising physicians, but rather qualified staff such as registered nurses or medical technicians who are trained to perform such services, but cannot do so without required supervision,” Ferragamo explains.

The justification for such a change is based on the fact that NPPs are already eligible to perform such services under many states’ scope of practice rules. These rules were initially implemented in May 2020 as a means of easing the burden on providers during the public health emergency (PHE). Following suit with a variety of other previously “temporary” guidelines, CMS has decided to permanently implement this new diagnostic supervision policy. According to CMS, NPPs “are authorized to receive payment under Medicare Part B for the professional services they furnish either directly or ‘incident to’ their own professional services.”

CMS considers the following sets of NPPs eligible for diagnostic supervision services:

• Nurse practitioners (NPs)
• Clinical nurse specialists (CNSs)
• Physician assistants (PAs)
• Certified registered nurse anesthetists (CRNAs)

Refresher: In the 2020 MPFS final rule, CMS added further autonomy to the role of NPP by stating that both physicians and NPPs can “review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the MPFS.”

To consider: According to NP and PA CMS guidelines, Medicare pays services “at 80% of the actual charge or 85% of the amount Medicare pays a physician under the Medicare Physician Fee Schedule (MPFS).”

Focus on More Payment Impacts

In addition to the CF rescue, the CAA offers other changes to Medicare rules focused on helping providers weather the financial impacts of the COVID-19 pandemic, such as the following:

Increased telehealth funding: The CAA allows an additional $250 million in Federal Communications Commission (FCC) funding for the COVID-19 Telehealth Program authorized under the CARES Act.

Extend sequester moratorium: The law provides a three-month extension of the moratorium on Medicare sequester payment reductions through March 31, 2021, further sparing physicians from additional cuts to Part B payments.

Provider Relief Fund (PRF): The CAA allows an additional $3 billion in PRF funding, and instructs providers to calculate lost revenue for PRF reporting purposes “using the Frequently Asked Questions guidance released by the Department of Health and Human Services in June 2020 including the difference between such provider’s budgeted and actual revenue budget if such budget had been established and approved prior to March 27, 2020.”

Geographic index: Look for a CAA extension of the Medicare work geographic index floor through Dec. 31, 2023.

More funding: CAA extends funding for key federal health programs, including the National Health Service Corps, Community Health Centers, State Health Insurance Assistance Program (SHIP), GME Teaching Centers, and more.