Medicare Compliance & Reimbursement

Split codes mean physicians can outsource EKG tests

If you're worried about having to perform a vast battery of tests on new Medicare patients for a low reimbursement next year, you're not alone. Here's what your colleagues and the Centers for Medicare & Medicaid Services  have to say about the situation.

Many doctors complained that the "Welcome to Medicare" exam doesn't reimburse enough to cover the laundry list of services the exam includes. CMS didn't offer much to set physicians' minds at ease in its final physician fee schedule, published in the Federal Register Nov. 15.

Many doctors had asked CMS to use the existing preventive medicine services codes (99381-99387) instead of creating a new G-code with 1.51 RVUs for the WTM exam. The preventive medicine codes allow more specificity as to the length of time spent with the patient, and may reimburse more than 1.51 RVUs.

But CMS insisted that the new initial physical exam would only take 53 physician minutes and 51 minutes of staff time, roughly equivalent to a level three new patient office visit plus EKG. The agency promised to keep looking at the data to see whether the benefit takes more time or work. Also, CMS agreed not to restrict medically necessary evaluation and management services on the same date as the physical exam to a level two or lower, as the agency had proposed.

To allow physicians and non-physician practitioners to make arrangements to have an outside provider perform the EKG, CMS split the initial physical exam into two codes: G0344 for the exam and G0366 for the EKG. CMS also added two more EKG codes as part of the exam, G0367, for tracing only, and G0368, for interpretation and report only.

CMS insisted that Congress had authorized the regulators to load more tests into the WTM exam than Congress called for in the Medicare Modernization Act.

Providers have complained that the new WTM exam will boost physician spending and lead to steep cuts in payment. But CMS Administrator Mark McClellan insisted in a conference call that the agency expects the exam to reduce spending overall by identifying costly problems earlier.

CMS Makes 'Welcome' Concessions

CMS did agree to make a few changes to the "Welcome to Medicare" exam. The agency changed language in the exam's descriptor to clarify that doctors should be looking for "modifiable risk factors for disease," or conditions where early detection could make a huge difference.

Also, CMS agreed to remove the requirement that physicians seek information on a patient's work and travel history and social activities, keeping only questions about diet, alcohol, tobacco and drug use and physical activities. The final rule will spell out that doctors should be looking for risk factors for depression, not just actual depression.

Instead of using the National Coverage Determination process to make changes to the tests required in the WTM exam, CMS will simply require that covered tests must be recognized by "national medical professional organizations."