Orthopedic Coding Alert

If you didn’t like the blended E/M pay idea, there’s good news.

On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released its final rule, with all the changes coming to Medicare in 2020 — as well as decisions on a few changes slated for 2021.

Much of the buzz surrounds all manner of evaluation and management (E/M) changes that will be happening this year and next; but there’s also the Medicare Physician Fee Schedule (MPFS) conversion rate, and more, to check out in the latest final rule.

Peer into the crystal ball to see what awaits you in 2020 — and beyond.

Conversion Factor Up a Nickel

As always, the conversion rate was hotly anticipated, as it affects every medical practices’ bottom line. CMS has increased the PFS conversion factor by about a nickel, setting it at $36.0896 for 2020. This isn’t a huge change, but there is a potential silver lining, experts said.

“With little change in the physician conversion factor for 2020, Medicare physician payments are expected to remain relatively flat,” reports Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “Although, with changes to work, practice expense, and malpractice relative value units [RVUs], the aggregate impact of changes will vary by specialty and service mix.”

So while the conversion factor will likely do little to bump up your revenue, the revaluing of certain procedures and services could make them more profitable in 2020. Check out the procedures your practice most often perform against a list of the RVU changes for the procedures to see if it’ll result in more money in 2020.

As Falbo pointed out, an RVU change is no guarantee of increased reimbursement.

“A lot of the RVUs have been revalued; some up, some down,” reminds Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.

E/M Overhaul on Schedule — With Some Alterations

The final rule contained no surprises regarding when the big changes to E/M services will take place. They are still going to happen on Jan. 1, 2021.

However, the 2020 final rule did put an end to CMS’s controversial proposal to blend E/M level payments. As it stood, the proposal was going to merge E/M levels 2-4 for both new and established patients and reimburse them at the same rate for 2021.

According to Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana this blending “would have caused a real issue with medical care, as why would a physician spend the time it takes to perform a 99214 [Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …] when they would get reimbursed the same as a 99212 (… A problem focused history; A problem focused examination; Straightforward medical decision making …),” notes Holle. “The other fear was that providers would try to get to that 99215 [… A comprehensive history; A comprehensive examination; Medical decision making of high complexity …] without showing medical necessity due to the payment reform.”

CMS agreed with Holle, saying in the final rule: “We believed that the single blended payment rate for E/M office/outpatient visit levels 2-4 better accounted for the resources associated with the typical visit.”

Power to the people: The feedback this proposal generated gave CMS pause. “Many stakeholders have continued to express objections to our assignment of a single payment rate to level 2-4 office/outpatient E/M visits stating that this inappropriately incentivizes multiple, shorter visits and seeing less complex patients,” the final rule states.

“Therefore, we proposed to establish separate values for Levels 2-4 office/outpatient E/M visits for both new and established patients.”

So, if you’re ever wondering if you should bother submitting comments to CMS regarding the final rule, here is proof positive that they are listening.

Big E/M Changes Still on Horizon

CMS might have scrapped the blended payment idea on E/Ms, but it is going ahead with its decision to let you use either medical decision making (MDM) or time to select the level of the outpatient E/M service in 2021. It is also deleting 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …).

These  changes will “bring Medicare in line with what will be in CPT® in 2021, which should simplify matters for practices as compared to having Medicare-specific rules,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Falbo applauds these 2021 measures. “This will make coding easier for the physicians, who can understand MDM as the important factor and not get downcoded because they missed a given element of the history or exam,” she says. “This gives the physician more clinical autonomy to document the relevant history and exam based on their clinical judgement of the patient’s condition.”

And as for the deletion of 99201, Hauptman was all for it. “Providers are not using this code very often; 99201, as defined, doesn’t actually reflect good medicine,” she explains. “A new patient, however, minor the problem, would still require some history retrieval and perhaps an expanded exam. The decision-making would also be higher than what is illustrated in the 99201 description.

“Thus, it makes sense to delete it.”