General Surgery Coding Alert

Keep telehealth coverage in line with this update.

With rulings on shared evaluation and management (E/M) visits, telehealth coverage, teaching physicians and more, the 2022 Medicare Physician Fee Schedule (MPFS) will affect coverage for your surgeons’ work this year.

Although Congress averted the worst of the conversion factor (CF) reduction to $33.5983 that would have dramatically impacted pay for your services (see “Feds Rescue Medicare Providers from Massive Pay Cuts” in this issue), there’s still a lot to learn from what the Centers for Medicare & Medicaid Services (CMS) had to say in its final rule. We’re here to help you check it all out.

Incorporate Changes to Split/Shared E/M Services

When your surgeon performs an E/M visit with another physician this year, you need to know about some 2022 provisions about split/shared visits. CMS is continuing its current policy allowing billing of certain ‘split’ or ‘shared’ E/M visits by a physician when the visit is performed in part by both a physician and a non-physician practitioner (NPP) who are in the same group, and the physician performs a substantive portion of the visit. “CMS is limiting split or shared to E/M codes only, not procedures,” says Michael A. Granovsky, MD, CPC, FACEP, president of LogixHealth, a national coding and billing company.

Plus, CMS offers other insight on split/shared services in the rule, including how time factors into the E/M visits, reporting for new and established patients, modifiers, documentation, and codification of the revised policies.

Important: In a new definition of split/shared visits, CMS explains that whoever provides the “substantive portion of the visit” bills for the services — whether it’s the physician or the NPP. “For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time),” CMS says in the fact sheet. But “by 2023, the substantive portion of the visit will be defined as more than half of the total time spent.”

Table 26 from the final rule details the possibilities of determining the substantive portion of different visit types. “You can expect pushback from many physician groups, who will find it much more burdensome to bide by this new definition of substantive, and will be pushing to retain medical decision making as an option,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, former CPT^® Editorial Panel member in Pasadena, California.

Follow the Evolution of Telehealth

The final rule announces that codes added to the telehealth services list on a Category 3 temporary basis for the Public Health Emergency (PHE) will remain on the Medicare telehealth list through the end calendar year (CY) 2023. “This allows time to get more evidence and comments on the Category 3 codes to support possible permanent addition to the list, or possible removal from the list,” CMS states in a fact sheet on the rule (www.cms.gov/files/document/mm12519-summary-policies-calendar-year-cy-2022-medicare-physician-fee-schedule-mpfs-final-rule.pdf).

“Category 3 telehealth services in the final rule include home visits for established patients, emergency department visits, critical care services, and hospital and nursing facility discharge day management services,” says partner attorney Eric D. Fader with law firm Rivkin Radler LLP in online legal analysis. “CMS also extended the inclusion of two new cardiac rehab codes through calendar year 2023.”

E/M: The extension includes the office E/M services (99202- 99215), among several other codes. CMS aims to analyze data through 2023 to evaluate the benefits of providing these services via telehealth before deciding whether they could potentially add them to the permanent list of approved telehealth services.

Physician Assistants Can Directly Bill Medicare

You may remember that Section 403 of the Consolidated Appropriations Act, 2021 (CAA) mandated the removal of the federal requirement to only pay physician assistants’ (PAs) employers or independent contractors for services provided by PAs.

Starting on January 1, 2022, “PAs may bill Medicare directly for their professional services, reassign payment for their professional services, and incorporate with other PAs and bill Medicare for PA services,” CMS’ fact sheet about the final rule says.

Look for Stricter Teaching Physician Criteria

To better align with the 2021 changes to office/outpatient E/M visit codes, CMS revised its teaching physician policies for selecting the correct E/M visit levels. “When time is used to select the office/outpatient E/M visit level, only the time spent by the teaching physician in qualifying activities, including time that the teaching physician was present with the resident performing those activities, can be included for purposes of visit level selection,” notes the fact sheet.

“CMS clarifies that Medicare will not pay teaching physicians for shared services unless the physician exercises full, personal control over the portion of the case for which the physician is seeking payment,” Granovsky explains.

Here’s why: “Under the primary care exception, time cannot be used to select visit level. Only MDM [medical decision-making] may be used to select the E/M visit level, to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services,” CMS says.

Resource: Find the rule in the Federal Register at www.federalregister.gov/documents/2021/11/19/2021-23972/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part