Primary Care Coding Alert

E/M, immunization fees could be going up, while prolonged service coding could get tricky.

The Centers for Medicare & Medicaid Services’ (CMS’) proposed Physician Fee Schedule (PFS) for 2021 is a perfect reflection of these current times, as it contains some potentially good news, some potentially bad news, and some confusing news.

Like previous years, many of these proposals for the policies and payments may not be implemented in the upcoming year. But here’s a glimpse at what could affect primary care coding and billing in 2021.

Payment Increases Planned for Some E/Ms, Immunization Administrations …

Many of your most-used evaluation and management (E/M) codes are earmarked for rate increases this year. Office and outpatient E/Ms, for example, could well be going up, with some hefty increases slated for established patient visits:

On average, “E/M RVUs [relative value units] are going up around 20 percent,” notes Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC. In addition, “CMS is also extending the increase in office/outpatient 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.

The potential good news also extends to one of primary care’s most commonly performed procedures: immunization administration. The proposal calls for the 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered), 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)), and HCPCS codes G0008-G0010 (Administration of influenza virus/ pneumococcal/hepatitis B vaccine) RVUs to be “based on a nonfacility total RVU value of 0.79 in place of the current nonfacility total RVU of 0.40. The corresponding add-on codes, +90461 and +90472, would be valued at half of the RVUs of 90460/90471, which is a slight increase over the 0.36 nonfacility total RVU currently assigned to them” explains Blanchard.

… While CF May Be Going Down

Meanwhile, the proposal calls for “the conversion factor [CF] to go down by about 11 percent,” Blanchard notes. “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.

As a reminder: The CF is the final multiplier in the complex CMS payment formula known as the resource-based relative value scale (RBRVS), where the three RVU elements involved in providing services and procedures — work (W), practice expense (PE) and malpractice insurance (MP) — are all multiplied by geographic practice cost indices (GPCI), added together, then multiplied by the CF to produce a dollar value for those services and procedures.

This part of the proposed rule will be hotly contested by many medical associations and organizations, including the American Medical Association (AMA), as they believe such a large reduction will be devastating to healthcare providers while the COVID-19 public health emergency (PHE) is having such a negative impact on the economy. (You can view the AMA’s position by going to: https://www.ama-assn.org/practice-management/medicare/cutting-medicare-pay-during-covid-19-pandemic-doesn-t-make-sense.)

Telehealth Expansion Continues Apace …

The explosion in telehealth usage during the PHE has also inspired CMS to propose adding 99XXX (Prolonged office or other outpatient evaluation and management service(s) …; each additional 15 minutes …), 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.

… While the Prolonged Service Proposal is Perplexing

Code 99XXX, which CPT^® will designate as +99417 in 2021, also features in another, more confusing CMS proposal for next year.

“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 CPT^®’s instructions for +99417 that tell you to add the code on to 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 the total duration of the new patient visit hits 75 minutes or when the total duration of the established patient visit hits 55 minutes. CMS, on the other hand, would have you add the code onto 99205 when the time for the new patient visit hits 89 minutes or onto 99215 when the time for the established patient hits 69 minutes.

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

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.