Primary Care Coding Alert

And watch out for a possible CF reduction.

As always, Medicare’s Physician Fee Schedule proposed rule for CY 2022 contains a lot of proposals that will impact primary care if they are adopted. Here are four of the biggest that could affect you and your practice in just a few short months.

Will Immunization Administration Payments Go up in 2022?

“One thing that really stands out in the proposed rule is the continued deliberation about immunization administration payments that we’ve watched play out over the last several years,” notes Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC.

During those years, Medicare has reduced the payment for 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular), 90460/+90461 (Immunization administration through 18 years of age … with counseling by physician or other qualified health care professional; first or only component of each vaccine …); 90471/+90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine…); and 90473/+90474 (Immunization administration by intranasal or oral route; 1 vaccine…) as the following table shows:

 In comparison, on March 15, 2021, Medicare increased payments for COVID-19 vaccines from $16.94 to $40.00 for the first doses of the Pfizer and Moderna vaccines (billed with 0001A and 0011A respectively), from $28.39 to $40.00 for the second doses of these vaccines (billed with 0002A and 0012A respectively), and from $28.39 to $40.00 for the single dose Jannssen/Johnson & Johnson vaccine (billed with 0031A), prompting calls for CMS to revalue 90460/+90461, 90471/+90472, and 90473/+90474.

Medicare seeks detailed comments on the cost of vaccine supplies and administration and indicates it may use this information to create a new, more sustainable payment methodology for vaccine administration services under the fee schedule. As these codes are so important in primary care, “I recommend that readers weigh in on this important topic by submitting feedback,” says Blanchard.

Get Ready for a Possible Split/Shared Shake-Up

For 2022, Medicare is proposing to simplify its split/shared policy by “limiting the definition of split (or shared) visits to include only E/M visits in institutional settings.” In other words, Medicare no longer sees “a need for split (or shared) visit billing in the office setting, because the ‘incident to’ regulations govern situations where an NPP works with a physician who bills for the visit, rather than billing under the NPP’s own provider number.”

Medicare’s current policy allows split/shared billing if the physician performs “a substantive portion of the visit,” if the practitioners “are in the same group and furnishing the visit in specified settings,” and when the services are “furnished to established patients.” CPT^®, on the other hand, has no such restrictions and simply sums the total time “physicians and other qualified health care professional(s) [spend] assessing and managing the patient on the date of the encounter” in split/shared E/M encounters.

In its latest proposal, Medicare proposes to modify this policy and allow “the physician or NPP who performs the substantive portion of the split (or shared) visit [to] bill for the visit.” They are also proposing to define “substantive portion” as “more than half of the total time spent by the physician and non-physician practitioner performing the visit.”

The proposal also calls for providers to be able to count prolonged service time in split/shared encounters. Under this model, “the physician and NPP would sum their time together, and whomever furnished more than half of the total time, including prolonged time, (that is, the substantive portion) would report both the primary service code and the prolonged services add-on code(s), assuming the time threshold for reporting prolonged services is met.”

Last, Medicare is considering further tweaks to their split/shared policy

• by further defining the term “group” to align with the definition of “physician organization,” used elsewhere in regulations, or to require that the physician and NPP must be in the same clinical specialty, such that the “NPP is considered to be in the same specialty and subspecialty as the physician with whom they are working” in split/shared encounters;
• by requiring both physician and NPP to be identified in the medical record for split/shared encounters; and 
• by proposing an informational modifier be appended to split/shared claims for data-gathering purposes.

Pencil in These Possible PCM Codes for 2022

“Next year, Medicare is proposing to accept and pay for new CPT^® codes for Principal Care Management (PCM),” says Lori Carlin, CPC, COC, CPCO, CCS, Director, Professional Coding Services, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

The codes in question are:

• 99X22 (Principal care management services, for a single high-risk disease: with the following required elements: one complex chronic condition expected to last at least 3 months, and which places the patient at significant risk of hospitalization, acute exacerbation /decompen­sation, functional decline, or death, the condition requires development, monitoring, or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities; ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month)
• 99X23 (Principal care management services provided personally by a physician or other qualified health care professional, … each additional 30 minutes …)
• 99X24 (Principal care management services … first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month)
• 99X25 (Principal care management services, for a single high-risk disease…: each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional …).

“A patient would be eligible for PCM if they have a chronic condition that is expected to last at least three months. It would be a condition which places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death,” Carlin clarifies.

Will Your Bottom Line Go up in 2022?

Perhaps Medicare’s most concerning proposal, however, involves a large reduction in the conversion factor (CF) — the final multiplier that CMS applies to all service and procedure fees. For 2022, CMS is proposing a CF of $33.58, a 3.75 percent reduction from the 2021 conversion factor of $34.89, which is due to the expiration of a 3.75 percent increase in the 2021 conversion factor applied via Congressional legislation in December 2020.

(To view the full proposed rule, go to >public-inspection.federalregister.gov/2021-14973.pdf?utm_medium=email&utm_campaign=pi+subscription+mailing+list&utm_source=federalregister.gov. CMS will accept comments on the proposed rule electronically, via regular mail, and by express or overnight mail, until 5 p.m. on September 13, 2021. See page 2 of the proposed rule for further information).