Pulmonology Coding Alert

Hint: Proposal causes one pulmonary practice in our sample to lose $93,000 in one year.

Pulmonology practices have been able to rest easy during the past few years’ worth of fee schedule changes, but this year may have thrown a wrench into that bliss. CMS is proposing major changes to how E/M codes are documented, billed, and paid, which could cause a major upheaval to your systems if the agency finalizes these changes.

Background: CMS released its proposed Medicare Physician Fee Schedule (MPFS) for 2019 on July 12, and it includes what the agency is calling “historic” E/M documentation changes to the outpatient office visit codes (99201-99215). Those changes include the following:

• Use medical decision-making or time for outpatient E/M versus the current guidelines.
• Give physicians the option of using time as a factor even if counseling or care coordination are part of the medical equation.
• Put re-documenting aside and let providers “focus their documentation on what has changed since the last visit or on pertinent items that have not changed.”
• Give practitioners the option of accepting data plugged in by staff instead of timely re-entering.

If this sounds so appealing that you’re wondering if there’s a “catch,” note that there is. CMS is proposing a “new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services,” the agency said in a Fact Sheet about the change. The payment levels are proposed as follows:

• 99212-99215: $93 for each of these codes
• 99202-99205: $135 for each of these codes.

This would mean that payments for level five codes would go down, while pay for level two codes would go up. Practices that report a lot of level five codes (ie, practices who care for more complex patients that others) would be likely to lose money, but some practices would see gains, says Cyndee Weston, CPC, CMC, CMRS, executive director of the American Medical Billing Association (AMBA) in Davis, Oklahoma.

Check Out These 3 Pulmonary-Specific Examples of How Pay Could Change

To determine the impact that this change might have on pulmonary care practices, Pulmonology Coding Alert reviewed the utilization data for three different pulmonary care practices and calculated how it would impact each of them.

These calculations assume that the pulmonologists will earn $93 for each of the following codes under the proposal, and that they currently bring in the following average reimbursement for 99212-99215:

• 99212: $45
• 99213: $75
• 99214: $109
• 99215: $148

Impact to Practice 1: Pulmonologist in South Florida:

• 99212: Billed 28 times in one year – worth $1,260 today, worth $2,604 under proposal
• 99213: Billed 46 times in one year – worth $3,450 today, worth $4,278 under proposal
• 99214: Billed 399 times in one year – worth $43,491 today, worth $37,107 under proposal
• 99215: Billed 91 times in one year – worth $13,468 today, worth $8,463 under proposal

Total Difference: This practice earned $61,669 for these four codes under today’s payment structure, and would earn $52,452 under the proposal. This practice would see $9,217 less pay under the proposal for these four codes.

Impact to Practice 2: Pulmonologist in Western Kentucky:

• 99212: Billed 22 times in one year – worth $990 today, worth $2,046 under proposal
• 99213: Billed 469 times in one year – worth $35,175 today, worth $43,617 under proposal
• 99214: Billed 104 times in one year – worth $11,336 today, worth $9,672 under proposal
• 99215: Billed 63 times in one year – worth $9,324 today, worth $5,859 under proposal

Total Difference: This practice earned $56,825 for these four codes under today’s payment structure, and would earn $61,194 under the proposal. This practice would see $4,369 more pay under the proposal for these four codes.

Impact to Practice 3: Pulmonologist in Northwestern California:

• 99212: Billed 31 times in one year – worth $1,395 today, worth $2,883 under proposal
• 99213: Billed 86 times in one year – worth $6,450 today, worth $7,998 under proposal
• 99214: Billed 744 times in one year – worth $81,096 today, worth $69,192 under proposal
• 99215: Billed 1,531 times in one year – worth $226,588 today, worth $142,383 under proposal

Total Difference: This practice earned $315,529 for these four codes under today’s payment structure, and would earn $222,456 under the proposal. This practice would see $93,073 less pay under the proposal for these four codes.

Bottom line: One of the three practices would come out better under the proposal than it does now, but the two practices with higher utilization of levels four and five would lose money under the proposed changes. Of course, this doesn’t mean your pulmonologist will necessarily model the same results as these practices. If you know how frequently you reported each of these codes, you can perform a similar calculation to determine how the change would affect you.

Would Documentation Guidelines Hurt You?

Keep in mind that if the proposal is finalized, you would have to be ready to code your charts based on new criteria. For instance, if the code level ends up being based on medical decision-making (MDM) rather than the current method of history, medical decision-making, and exam, there could be a learning curve for some practices, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford Massachusetts. “MDM can be subjective – the risk table is not black and white unless you’re using the intervention column, which is probably historically the least relevant.”

Certainly, the inclusion of a suggested E/M change in the fee schedule proposal doesn’t mean that a change will actually happen. Keep an eye on Pulmonology Coding Alert for all the latest on whether CMS moves toward finalizing these proposals.

Resource: For a closer look at the MPFS proposed rule for CY 2019, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf.