Primary Care Coding Alert

The 2021 final rule is a mixed bag, say experts.

In Primary Care Coding Alert v22n10, we highlighted various proposals the Centers for Medicare & Medicaid Services (CMS) were considering implementing in the Physician Fee Schedule (PFS) for 2021.

In this issue, we revisit some of those proposals to see whether CMS adopted them on Dec. 1, 2020 when they released their final rule. We also asked two coding experts how they felt the final policies will affect your coding and billing this year, and here’s what they had to say.

The PHE Telehealth Expansion Becomes Permanent

What was proposed: Due to the COVID-19 public health emergency (PHE), CMS proposed expanding the Medicare telehealth code list, which included adding a number of codes used in primary care: 99XXX, which would eventually become +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time …); 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 …).

What has been finalized: In total, CMS has permanently added nine new codes to the Medicare telehealth list for CY 2021, including all the above codes (substituting its new prolonged services code, G2212, for +99417) along with G2211 (Visit complexity inherent to evaluation and management associated with medical care services …), +96121 (Neurobehavioral status exam …), and 90853 (Group psychotherapy …). In addition, CMS added a number of new codes on a category 3 basis, meaning that the codes “would remain on the Medicare telehealth services list through the calendar year in which the PHE for COVID-19 ends.” Of these, the following may come into play for primary care coding this year:

• Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT^® 99336- 99337)
• Home Visits, Established Patient (CPT^® 99349-99350)
• Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT^® 99469, 99472, 99476)
• Emergency Department Visits, Levels 1-5 (CPT^® 99281-99285)
• Nursing facilities discharge day management (CPT^® 99315-99316)
• Hospital discharge day management (CPT^® 99238- 99239)
• Subsequent Observation and Observation Discharge Day Management (CPT^® 99217; CPT^® 99224-99226)

The impact for 2021: Both the permanent and temporary additions to the telehealth list will prove to be beneficial for primary care. That’s because “having the opportunity to provide these via telehealth and be paid accordingly offers much-needed flexibility,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Office/Outpatient E/M Increases Finalized …

What was proposed: The 2021 proposed rule called for “E/M [evaluation and management] wRVUs [work relative value units] to go up around 20 percent,” says Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC reminded coders.

What has been finalized: CMS followed through on their promise, and the increases over 2020 wRVUs remain intact.

The impact for 2021: “This is very good news for primary care physicians, including employed primary care physicians whose salary may be tied to their RVU productivity, since the services they report most often, especially 99213 and 99214, will increase in value in 2021. This is part of the reason CMS projects family physicians, for example, will see a 13 percent increase in their Medicare allowed charges in 2021, even with the decrease in the conversion factor [CF] referenced below. Hopefully, other payers will follow suit,” Moore notes.

… But Immunization Rates Continue to Decrease ….