Pediatric Coding Alert

Payment rates, prolonged service confusion, and telehealth expansion top the list.

As they do every year, the Centers for Medicare & Medicaid Services (CMS) have published their proposals for the policies and payments that will eventually be solidified in the Physician Fee Schedule (PFS) for 2021.

Here’s a summary of the main components of the 2021 proposed rule that could affect your coding and your bottom line next year.

CF Goes Down, E/Ms Go Up

CMS’ proposals for payment rates next year could be good news for pediatric practices. “Evaluation and management [E/M] RVUs [relative value units] are going up around 20 percent, and the conversion factor [CF] is going down by about 11 percent,” notes Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC.

“Based on what we know so far, if the conversion factor ultimately remains unchanged — as often happens — we estimate that on average there would be a 25 percent increase in established patient E/M charges. If the conversion factor does change, the effect is closer to single digits,” Blanchard continues.

Additionally, “CMS is also extending the increase in office/outpatient visit E/M values to other services, including cognitive assessment and care plan services [99483] and transitional care management services [99495-99496],” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

But Will it Happen?

The CF reduction is a part of Medicare’s agreement with the federal government to maintain budget neutrality. But it may not go through. That’s because the American Medical Association (AMA) and other medical associations and organizations are expected to lobby congress to change their stance on budget neutrality while the COVID-19 public health emergency (PHE) is having such a devastating impact on the economy in general and healthcare in particular. (To view the AMA’s response, go to: https://www.ama-assn.org/practice-management/medicare/cutting-medicare-pay-during-covid-19-pandemic-doesn-t-make-sense.)

Potential Prolonged Services Problem

Another E/M code that features in the proposed rule is 99XXX (Prolonged office or other outpatient evaluation and management service(s) …; each 15 minutes …), which will be designated as +99417 in CPT^® 2021. But CMS’ proposal for it could be the possible cause of confusion among peds coders if it is implemented

“CMS is proposing to only permit 99XXX when the maximum time of 99205 or 99215 has been exceeded by 15 minutes,” explains Moore. This is not the same as the CPT^® instructions for +99417 that tell you to add the code onto 99205 or 99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) when these codes hit the maximum in their time ranges. So, for example, CPT^® tells you to add a unit of +99417 when 99205 hits 75 minutes or add a unit of +99417 when 99215 hits 55 minutes. CMS, on the other hand, would have you add the code onto 99205 when the time for the code hits 89 minutes or onto 99215 when the time for the code hits 69 minutes.

This means that “if CMS finalizes that proposal, physicians and coders will need to be aware that the CMS rules will differ from the CPT^® rules,” explains Moore.

Immunization Administrations Revalued

CMS is also proposing increases in the payment rates for 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional;…), 90471/+90472 (Immunization administration …), and HCPCS codes G0008-G0010 (Administration of influenza virus/pneumococcal/hepatitis B vaccine), which could also be good for pediatric practices.

“The proposed plan is to set value based on a non-facility total RVU value of 0.79 in place of the current non-facility total RVU value of 0.4. The add-on codes will also be valued more, as they are now at half of the RVUs of 90460/90471,” explains Blanchard.

Telehealth Expansion Continues Apace

CMS is also proposing to add 99XXX, 99483 (Assessment of and care planning for a patient with cognitive impairment …), 99334-99335 (Domiciliary or rest home visit for the evaluation and management of an established patient …), and 99347-99348 (Home visit for the evaluation and management of an established patient …) to the current telehealth list. Additionally, it is also seeking comments about adding other codes, either on a temporary or permanent basis, continuing its rapid expansion of telehealth that began with the PHE.

For a fact sheet on the CY 2021 Physician Fee Schedule proposed rule, visit https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4. To view the full CY 2021 Physician Fee Schedule and Quality Payment Program proposed rule, visit https://www.cms.gov/files/document/cms-1734-p-pdf. pdf. And to comment on the proposed rule, follow the instructions found at https://beta.regulations.gov/document/CMS-2020-0088-1604 and submit your comment before 5 PM on Oct. 5, 2020.