Pulmonology Coding Alert

Find out if PAs can bill Medicare directly.

After seeing the proposed rule earlier in 2021, pulmonology practices have been eagerly awaiting the final rule. Several changes in the Centers for Medicare and Medicaid Services (CMS) Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) final rule affect billing, payments, and care plans for your patients.

Read on to learn what the CY 2022 MPFS entails.

Understand Who’s Eligible for PR Coverage

In the proposed rule earlier in 2021, CMS proposed several revisions to Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Care Rehabilitation (ICR). CMS proposed revising the PR, CR, and ICR regulatory text to help improve consistency across the conditions. Additionally, CMS recommended adding COVID-19 as a covered condition for PR.

For CY 2022, CMS is finalizing the revisions for the following PR definitions to align more closely with those of CR and ICR:

• Individualized treatment plan
• Medical director
• Outcomes assessment
• Physician-prescribed exercise
• Psychosocial assessment
• Supervising physician

Originally, in the MPFS proposed rule, CMS proposed PR coverage for Medicare beneficiaries diagnosed with severe presentations of COVID-19 who require ICU hospitalization and continue to experience symptoms for at least four weeks after discharge. However, upon further review, CMS finalized expanding coverage beyond their original proposal.

In the final rule, CMS finalized PR coverage for beneficiaries “who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks.” This coverage applies to all beneficiaries regardless of hospitalization and where the patient received treatment for COVID-19. While a positive COVID-19 test isn’t necessary for beneficiaries to be eligible for coverage, they must experience continuing COVID-19 symptoms, including respiratory dysfunction, for at least four weeks. The timeframe may begin when the symptoms begin.

“This is of particular interest to the patient who can now utilize this service without fear of high out-of-pocket costs, and have a better pathway to recovery,” says Carol Pohlig, BSN, RN, CPC and Manager, Coding & Education in the Department of Medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Scenario: A Medicare patient visits your pulmonology practice after recovering from COVID-19, coded to U07.1 (COVID-19). The patient’s COVID-19 symptoms didn’t require hospitalization, but did persist for four weeks. Additionally, the patient is still experiencing shortness of breath, fatigue, and physical limitations that hinder their quality of life. After performing a physical exam and multiple pulmonary function tests (PFTs), including 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation) and pulse oximetry, the physician determines the patient is a candidate for pulmonary rehabilitation.

Billing Split/Shared Visits for Critical Care Services

Earlier in 2021 in the proposed rule, CMS proposed defining split/shared visits as evaluation and management (E/M) visits in a facility setting where both a physician and an advanced practice provider (APP), who are in the same group, provide care. The proposal also recommended modifying the policy to allow physicians and APPs to bill for split/shared visits for new and established patients, as well as for critical care and select Skilled Nursing Facility/Nursing Facility (SNF/NF) E/M visits.

In the MPFS final rule, CMS finalized the split/shared visit definition as proposed. Additionally, CMS finalized how to define a “substantive portion” for a split/shared visit. A substantive portion is more than half of the time spent by the APP and physician delivering care. However, to allow for an adjustment period to “establish systems to track and attribute time for split (or shared) visits,” the substantive portion definition will take effect on January 1, 2023. In CY 2022, the practitioner who performs more than 50 percent of the history of present illness, physical exam, or medical decision making (MDM) — or spends more than half of the total time — is the provider who performed the substantive portion of the visit and can bill for the split/shared E/M visit.

The change in billing for split/shared services for office and inpatient E/M visits “will financially impact the practice, particularly for inpatient services,” says Pohlig, as typical inpatient workflows staff several APPs who perform the bulk of the services, which allows the physician to make rounds on all the patients. When the physician is not able to perform more comprehensive services on all patients, they will have to accept a reduced reimbursement rate. “This could cause a change in the workflows and resource inequities for patient care,” Pohlig says.

Like E/M visits, CMS proposed allowing physicians or APPs to bill for split/shared visits in critical care. In the proposed rule, CMS recommended practitioners would report CPT^® code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30 to 74 minutes of critical care services provided to a patient on a given date. You would report each additional 30-minute time increment starting at 75 minutes with +99292 (…; each additional 30 minutes (List separately in addition to code for primary service)). Additionally, you’ll need to append the code with a to-be-created modifier for shared services to allow for tracking and auditing by the payer.

CMS finalized the proposal to allow physicians and APPs to bill for split/shared visits in critical care effective January 1, 2022. Previously, split/shared visits in critical care were reported only when two physicians from the same group provided critical care. Critical care provided by a physician and APP had to be separately reported under each provider’s name, with only one being able to report 99291. Effective January 1, a physician and APP, in the same group, can total their time spent and report it under the person who spent the majority of the time delivering critical care. In the final rule, CMS finalized that either the physician or APP may report 99291 for the first 30 to 74 minutes of “critical care services provided to a patient on a given date.” The provider can only report 99291 once per day, regardless of whether the time spent with the patient is not continuous on the date. For every additional 30 minutes provided to the same patient, +99292 is reported on the same claim by the provider who spends the majority of the total service.

Simplifying PA Service Reimbursement

Prior to the CY 2022 MPFS final rule’s implementation, physician assistants (PAs) were authorized to furnish physician-equivalent services but were unable to bill the Medicare program directly. According to section 1842(b)(6)(C)(i) of the Social Security Act, the “payment for PA services must be made to the PA’s employer.” This contrasts with billing for services furnished by nurse practitioners (NPs) and clinical nurse specialists (CNSs), who are authorized to provide equal services and care as a PA.

Signed into law on December 27, 2020, the Consolidated Appropriations Act (CAA) includes section 403, which amends section 1842(b)(6)(C)(i) of the Social Security Act to remove the requirement for PAs to bill their services only to their employer starting January 1, 2022.

CMS finalized their proposal to implement section 403 of the CAA. This allows PAs to directly bill for their services effective January 1, 2022.

The final rule was published in the Federal Register on November 19, 2021, and is available at www.federalregister.gov/public-inspection/2021-23972/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part.