Primary Care Coding Alert

E/M revisions continue apace, while PCM gets a much-needed introduction.

More evaluation and management (E/M) changes. A new category of care management. And plenty of new codes to go along with them.

There is a lot to unpack in the 2,745-page 2020 Physician Fee Schedule (PFS) final rule, which the Centers for Medicare and Medicaid Services (CMS) published on November 1, 2019. Here are some of the big changes, along with some expert opinion to help you keep track of it all.

E/M Changes Finalized

Perhaps the biggest takeaways from the 2020 final rule involve the much-awaited revisions to the current E/M guidelines, most of which will take place on Jan. 1, 2021.

A number of the changes, such as the decision to let you use either medical decision making (MDM) or time to select the level of the outpatient E/M service, the decision to adopt the CPT^® interpretive guidelines for MDM, and the decision to delete E/M code 99201 (Office or other outpatient visit for the evaluation and management of a new patient …) “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 to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Experts have also welcomed CMS’s decision to abandon its blended payment proposal, which would have seen E/M levels 2-4 paid for at the same rate, with one rate for new patients and another for established patients. As it stood, the proposal “would have caused a real issue with medical care, as why would a physician spend the time it takes to do a 99214 visit when they would get reimbursed the same as a 99212,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “The other fear was that providers would try to get to that 99215 without showing medical necessity due to the payment reform,” adds Holle. 

Prolonged service overhaul: In addition, the way you report prolonged services will change dramatically. As of Jan. 1, 2021, you will use CPT^® code 99XXX (Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)) “when time is used for code level selection and the time for a level 5 office/outpatient visit (the floor of the level 5 time range) is exceeded by 15 minutes or more on the date of service,” according to CMS.

The changes have received mixed reviews from coding experts. On the one hand, “Medicare using CPT^® codes is always preferable because practices don’t have to vary their reporting by payer,” notes Moore. So, “there should be no problem with the code being adopted by private payers such as BCBS, Aetna, and Cigna,” agrees Holle.

However, because of confusion about how codes 99358/+99359 (Prolonged evaluation and management service before and/or after direct patient care …) will relate to 99202-99215 in 2021 and beyond, CMS has decided 99358/+99359 will not be payable in association with office/outpatient E/M visits beginning in CY 2021. “CMS no longer recognizing 99358/+99359 is more problematic, because it adds to the uncertainty surrounding how these codes as currently described will relate to the revised office/outpatient visit codes when the latter go into effect in 2021,” Moore points out.

Extensive Care Management Changes Are Coming

In addition to revisions that will unbundle transitional care management (TCM) services from a number of other services and some minor changes to the chronic care management (CCM) guidelines, CMS has also finalized plans to introduce another form of care management — principal care management (PCM) — beginning Jan. 1, 2020.

PCM describes care management services for one serious chronic condition or high-risk disease, which you will be able to document using HCPCS codes G2064 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management at least 30 minutes of physician or other qualified health care professional time per calendar month…) and G2065 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month…). The codes can be billed by either a primary care practitioner or a specialist overseeing the patient’s care, but only one provider will be able to bill for a specific condition.

Again, the decision has its pluses and minuses. The codes fill “an apparent gap in coding related to care management, in that the existing chronic care management codes require a patient to have two or more chronic conditions, and there is no code for chronic care management of the patient with a single condition,” Moore observes.

However, “CMS should have either a definition of what a ‘high-risk disease’ truly is or a list so that practices would really understand when to use this type of code,” argues Holle. Moreover, “CMS would allow these codes to be reported for patients with multiple conditions when a particular physician was managing just one of them, which would move away from the continuous, comprehensive, and coordinated value-based care and primary care CMS has otherwise been encouraging as a cost-effective way to care for Medicare patients,” believes Moore.

The bottom line: Finally, the best news of all is that your revenue for next year will increase slightly, as the final 2020 Medicare PFS conversion factor will be $36.0896, up by about a nickel from this year.

To view the full PFS final rule for 2020, go to s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf. And stay tuned for more in-depth coverage of these changes right here in Primary Care Coding Alert.