Orthopedic Coding Alert

No increase in pay for providers this year.

The final rule has finally been published, and the bag is decidedly mixed.

First things first: The conversion rate, which is the headliner in every final rule, was reduced slightly. There are also several other tidbits that will be of interest to neurosurgery coders as they tackle their claims in 2022.

Check out what the Centers for Medicare & Medicaid Services (CMS) had to say in its final rule.

Conversion Factor Goes Down in 2022

Heading into 2022, CMS proposed a conversion factor (CF) of $33.5848; but after public comments, they finalized a CF of $33.5983. This is still a lower value than the 2021 CF of $34.8931 by $1.2948. The Medicare Physician Fee Schedule (MPFS) final rule indicates CMS arrived at the 2022 CF using the 2021 CF without the 1-year, 3.75 percent increase provided by the Consolidated Appropriations Act (CAA) and multiplied it by the budget neutrality (BN) adjustment.

Public response: The significant CF reduction as the COVID-19 public health emergency (PHE) continues hasn’t gone unnoticed by healthcare organizations. The American Medical Association (AMA) is urging Congress to act to prevent further financial casualties.

“The AMA is strongly advocating for Congress to avert this and other looming cuts to Medicare physician payments that, overall, will produce a combined 9.75 percent cut for 2022.

This comes at a time when physician practices are still recovering the personal and financial impacts of the COVID public health emergency,” says AMA President, Gerald E. Harmon, MD, in a statement. “Congress is beginning to recognize that this financial instability could limit health care access for Medicare patients” (URL: www.ama-assn.org/press-center/press-releases/ama-statement-physician-fee-schedule-final-rule).

CMS Clarifies Split/Shared Rules

“CMS is proposing to continue 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 nonphysician practitioner [NPP], who are in the same group and the physician performs a substantive portion of the visit,” explains Michael A. Granovsky, MD, CPC, FACEP, president of LogixHealth, a national coding and billing company. “CMS is limiting split or shared to E/M [evaluation and management] codes only, not procedures.”

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, 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, Granovsky says.

Medicare Telehealth Continues Evolution

CMS is continuing to monitor the “Category 3” codes that it temporarily added to its Medicare telehealth services list during the COVID-19 PHE. But, the rule does finalize keeping “certain services” on the list through Dec. 31, 2023, to give CMS more time to evaluate the services, the fact sheet indicates.

“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.”

Behavioral health: CMS also added audio-only communications to its definition of interactive telecommunications system for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders offered to established patients in their homes, the rule indicates. A new modifier for these services was also finalized in the rule.

CMS Makes CAA Mandate for PA Services Official

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 the PAs by Jan. 1, 2022. Now, 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,” the fact sheet says.

Check Out Teaching Physician Payment Update

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.

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 at https://public-inspection.federalregister.gov/2021-23972.pdf.