Orthopedic Coding Alert

… but there’s good news on the telehealth front.

Late last year, Medicare released its 2021 final rule, which includes news on the Medicare Physician Fee Schedule (MPFS) and an update on the telehealth expansion. Coders that want to stay atop their claims and max out rightful reimbursement need to be up on these rules, and fast.

Why? Experts are already seeing 2021 as being a transformative one — and it’s only January. “It feels like a ‘wait and see’ year to me. I think we will continue to see all kinds of changes in the way healthcare is provided in the next year or two,” according to Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Here’s a look at how the final rule will most affect your coding in 2021.

Conversion Factor Faces a Fall

Despite industry protestations, the final 2021 MPFS conversion factor is $32.41, a decrease of $3.68 from the 2020 MPFS conversion factor of $36.09. This move has experts fretting, even though the Centers for Medicare & Medicaid Services (CMS) is claiming the increase in relative value units (RVUs) for some evaluation and management (E/M) services should offset the cut conversion rate.

“Provider groups are concerned that the Medicare Physician Fee Schedule rule for 2021 would exacerbate the financial challenges physicians are already facing during the COVID-19 pandemic, including lack of adequate telehealth reimbursement and sustainable practice revenue,” according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Bucknam took it a step further. “The decrease in the conversion factor is going to hurt practices in a time when healthcare is already reeling because of COVID. Many providers have seen the nature of their practices change dramatically, and not in a good way, and it looks like many of these changes will continue well into next year and some things may be changed forever,” she says.

The MPFS conversion factor could lessen reimbursement for some practices, and “may cause some practices to close. Boy, is that a negative assessment, but I think it’s true,” says Bucknam. “Other practices will need to get prepared to think about healthcare in very new ways and that may be hard for some practices.”

E/M RVUs Will Ease the Pain, Says CMS

Medicare is increasing the RVUs “for common office/outpatient E/M services, including maternity care bundles, emergency department [ED] visits, end-stage renal disease capitated payment bundles, and physical and occupational therapy evaluation services,” Falbo explains.

“CMS said in the final rule that the increases are meant to support primary care clinicians who are facing a growing number of Medicare beneficiaries, including many with one or more chronic conditions. The agency also believes the final rule will also aid other clinicians by reducing E/M documentation burden through a more streamlined reporting process for E/M levels,” concludes Falbo.

This offset will not even the books at a lot of practices, Bucknam opines. “I doubt that we will see much of an offset. Not every practice is highly dependent on E/M. Surgeons, who are not really doing elective surgery at this time, are going to have fewer E/M encounters. Primary care is seeing a decrease in preventive care and other services that people may see as elective.

“It’s hard to see how such a drastic decrease will be offset under these circumstances. Some specialties may do fine, but I think most will be hurt,” she continues.

Telehealth Services Continue Upward Trajectory

CMS is adding dozens of services to the telehealth approved list on a category 3 basis, including:

• Domiciliary, rest home, or custodial care services, established patients (99336-99337)
• Home visits, established patient (99349-99350)
• Emergency department visits (99281-99285)
• Nursing facilities discharge day management (99315-99316)
• Psychological and neuropsychological testing (96130-+96133; 96136-+96139)
• Therapy services, physical and occupational therapy (97161-97168; 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
• Hospital discharge day management (99238-99239)
• Critical care services (99291-+99292)
• Subsequent observation and observation discharge day management (99217; 99224-99226)

Note: This is not a complete list; CMS added more codes than these to the category 3 list. See the final rule or the CMS release for more info.

“Category 3 describes services added to the Medicare telehealth list during the public health emergency (PHE) for the COVID-19 pandemic (COVID-19 PHE) that will remain on the list through the calendar year in which the PHE ends,” according to a CMS release.

CMS is also adding the following services to the approved telehealth list on a category 1 basis. “Services added to the Medicare telehealth list on a category 1 basis are similar to services already on the telehealth list,” according to the CMS release:

• Group Psychotherapy (90853)
• Psychological and Neuropsychological Testing (+96121)
• Domiciliary, Rest Home, or Custodial Care services, Established patients (99334-99335)
• Home Visits, Established Patient (99347-99348)
• Cognitive Assessment and Care Planning Services (99483)
• Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M) (HCPCS code G2211)
• Prolonged Services (HCPCS code G2212)

Experts found a lot to like about the telehealth expansion.

“I think that telehealth, and all types of telemedicine services, are the future of healthcare,” Bucknam says. “Providers who don’t get on board with this will find that they have missed the boat. I think that telemedicine will continue to expand and that providers need to be prepared to make healthcare easier for their patients.”

Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America, calls the expansion a “terrific step,” but cautions against looking too far down the road. “Once the PHE is over, the demographic constraint is still at play for rural areas. Also, this development could still have a negative impact on patients’ health for those living in metropolitan areas,” explains Hauptman.

To read the CMS release on the final rule, go to https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1. You can find the entire final rule at https://www.cms.gov/files/document/12120-pfs-final-rule.pdf.