Otolaryngology Coding Alert

See what changes CMS has in store for E/M reporting and reimbursement.

As you’ve been expecting for some time, the Centers for Medicare and Medicaid Services (CMS) recently published the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. In Volume 21, Number 2 of the Otolaryngology Coding Alert, you were briefed on the new Patients Over Paperwork initiative and how it may impact your practice.

This month, the focus shifts toward the proposed evaluation and management (E/M) changes for the 2021 CY. In this proposal, CMS outlines “payment, coding and additional documentation changes for E/M office/outpatient visits.” Most importantly, these changes will have a profound impact on reimbursement for mid-range E/M codes.

Read further for a complete breakdown of the proposal and how you are likely to be impacted.

Identify Individual Components of Proposed E/M Changes

With a goal of simplification in mind, CMS is proposing a sweeping set of changes to E/M office and outpatient visits. The first policy revision involves streamlining payments for mid-range E/M visit codes by reimbursing levels 2 through 4 under one flat rate:

• “Reduction in the payment variation for E/M office/outpatient visit levels by paying a single rate for E/M office/outpatient visit levels 2 through 4 for established and new patients while maintaining the payment rate for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients.”

More specifically, CMS proposes a $90 flat rate payment for levels 2 through 4 for established patients and a $130 flat rate for levels 2 through 4 for new patients. Alternatively, CMS will keep level 5 new and established patient payments at $211 and $148, respectively. Reimbursement for level 1 codes will decrease from $45 to $44 for new patients and increase from $22 to $24 for established patients.

Note: For new primary care and non-procedural care patients, CMS will reimburse $130 for levels 2 through 4. For established primary care and non-procedural care patients, CMS will reimburse $103 for levels 2 through 4.

Get Familiar With New Add-On Codes

While much of this information might come as a surprise to physicians, billers, and coders alike, it’s the levels 2 through 4 flat rate that is sure to raise the most concerns. Obviously, without any further intervention, there would undoubtedly be backlash from those providers who don’t believe that levels 3 and 4 should be reimbursed the same as a level 2 visit. That’s where the following two CMS guidelines come into play:

• “Implementation of add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care, though they would not be restricted by physician specialty. These codes would only be reportable with E/M office/outpatient level 2 through 4 visits, and their use generally would not impose new per-visit documentation requirements; and
• “Adoption of a new ‘complex’ and ‘extended visit’ add-on code for use only with E/M office/outpatient level 2 through 4 visits to account for the additional resources required when practitioners need to spend extended time with the patient.”

As you can see, the provider is not necessarily out of luck when it comes to billing for a level 3 or 4 E/M service of moderate to high complexity. Instead, you will have the option of reporting a “complex” and “extended visit” add-on code in addition to the E/M level 2 through 5 service:

• GCG0X — Visit complexity inherent to E/M associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, or interventional pain management-centered care
• GPRO1 — Prolonged E/M or psychotherapy services(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; 30 minutes.

Currently, there isn’t a great deal of information elaborating further on these two add-on codes. Assuming the E/M visit is associated with one of the specialties listed in the GCG0X code description, you should consider this add-on code when the provider documents a higher degree of complexity than what is typically involved in level 2 through 5 visits. On the other hand, you should report add-on code GPRO1 when the level 2 through 5 service extends at least 30 minutes longer than the time allotted in the respective reference time for the E/M code.

For instance, E/M code 99212 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 10 minutes face-to-face with the patient and/or family) has a typical time estimation of 10 minutes. If the provider documents 40 or more minutes and what was done during the prolonged time, you may consider reporting GPRO1 with 99212. However, as you will see next month, it may be in your provider’s best interest to code the underlying E/M visit based exclusively on time, rather than the 1995/1997 E/M documentation guidelines.

Plan as if 2021 Changes are Concrete

While CMS certainly left the door open for a further extension beyond 2021, it’s in your best interest to prepare as if these changes will be final come 2021. The critical response to these changes is sure to be a mixed bag, but numerous coders feel that these changes will ultimately come to benefit both provider and payer.

“I believe once the providers and coders become familiar with the new guidelines it will be beneficial to all,” says Julie Leonard, CPC, CCS, CPCO, ACS-AN, RCC, CRCR, associate director at Kohler HealthCare Consulting in Woodstock, Maryland. “While providers will have fewer documentation hoops to jump through, they will, however, need a very strong coding staff in order to capture all the revenue due to them with the add-on codes. Once providers and their staff understand the new guidelines and reimbursement structure, I believe it will be a revenue neutral change with less ‘administrative burden’ and, hopefully, more time with patients.” Leonard explains.

Keep an eye out for the next of Otolaryngology Coding Alert where we’ll discuss scenarios such as these and more about the proposed 2021 E/M policy changes.