Pulmonology Coding Alert

Plus: Post-COVID telehealth options may get extended.

Pulmonology practices have been anticipating the Medicare Physician Fee Schedule (MPFS)—and for good reason. You’ll find several changes suggested in the proposed rule that could affect billing, payments, and care plans for your patients, if the proposal is finalized.

On July 13, Centers for Medicare & Medicaid Services (CMS) issued its Calendar Year (CY) 2022 MPFS proposed rule. The highlights for the proposed rule include adjustments in how physician assistants can bill the Medicare program, expanded telehealth options, and proposals to pulmonary rehabilitation language and coverage. Plus, CMS also reconsiders how to bill split (or shared) visits regarding critical care services.

Look for Possible Pulmonary Rehabilitation Changes

Under section III.H, you’ll find proposed revisions to Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Care Rehabilitation (ICR). Several proposed changes are aiming to help improve accuracy and consistency across the three specialties, which could help stakeholders understand and employ pulmonary rehabilitation, cardiac rehabilitation, and intensive care rehabilitation programs.

In the 2022 proposed rule, CMS is proposing conforming terminology, definitions, and requirements, where appropriate, between pulmonary rehabilitation, cardiac rehabilitation, and intensive care rehabilitation to help streamline the information and make it clearer.

For CY 2022, CMS is also proposing adding COVID-19 as a “covered condition for PR for certain beneficiaries.” Under section 410.47(a) of the 42 CFR 410.47, pulmonary rehabilitation is specified as a “physician-supervised program for COPD and certain other chronic respiratory diseases” (URL: www.govinfo.gov/content/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec410-47.pdf). The Centers for Disease Control (CDC) has used the term “post-COVID conditions” to describe symptoms that have persisted for more than four weeks after the initial infection, and CMS is proposing that COVID-19 be considered chronic when symptoms continue to present for more than four weeks.

“The symptoms [of COVID-19] can create a vicious cycle by which the patient cannot perform normal daily activities. This inactivity leads to deconditioning, allowing further worsening of the symptoms,” writes George Debal, MD, of Parkview Physicians Group (Source: www.parkview.com/community/dashboard/the-importance-of-pulmonary-rehab-for-covid-19-patients).

CMS is proposing that pulmonary rehabilitation be covered for Medicare beneficiaries who have been diagnosed with severe manifestations of COVID-19. You should define severe manifestations as “requiring hospitalization in the ICU or otherwise, and who experience continuing symptomatology, …, for at least 4 weeks post discharge.”

Physicians and APPs May Soon Be Able to Bill Split/Shared Visits for Critical Care Services

This year, CMS is proposing to allow split (or shared) visits involving critical care services. Current CMS policy dictates that you cannot bill critical care services as split (or shared) services. The proposed rule acknowledges the evolution of medicine, documentation, and billing over the past several years creates a team-based approach to care and would allow physicians and advanced practice providers (APPs) to combine their time for critical care services if they meet the shared services criteria as it applies to location, group assignment, and specialty. This is similar to the CY 2021 PFS final rule policy regarding office evaluation and management (E/M) visits, and the definition outlined by the AMA in the CPT^® manual.

CMS is proposing that physicians and APPs may bill for split (or shared) visits for new and established patients during initial and subsequent visits. Using the CPT^® E/M Guidelines, CMS is also proposing a list of activities that could count toward the total time when determining the substantive portion.

Like E/M visits, when billing for split (or shared) visits in critical care, the proposed rule indicates the physician or APP 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. Each additional 30-minute time increment starting at 75 minutes would be reported with 99292 (…; each additional 30 minutes (List separately in addition to code for primary service)). Additionally, when two or more practitioners spend time jointly meeting with the patient or discussing the patient, the time may be counted only once when reporting the split (or shared) critical care visit.

Will PAs Be Allowed to Bill Medicare Directly? Find Out.

According to section 1833(a)(1)(O) of the Social Security Act, physician assistants’ (PAs), nurse practitioners’ (NPs), and clinical nurse specialists’ (CNSs) payment amount for services is “equal to 80 percent of the lesser of the practitioner’s actual charge or 85 percent of the amount that would be paid to the physician under the PFS.” NPs and CNSs are authorized to bill Medicare and receive payment directly for their services, but payment for services for PAs must be made to the PA’s employer. The CMS regulation at section 410.74(a)(2)(v) stipulates that PA services will be covered under Medicare Part B only when the PA’s employer issues the billing. Due to this requirement, physician assistants “are precluded from directly billing the Medicare program and receiving payment for their services,” according to the CY 2022 Proposed Rule.

CMS is proposing to amend certain areas of the regulations to reflect the amendment made in section 403 of the Consolidated Appropriations Act of 2021. Specifically, CMS is proposing that section 410.74(a)(2)(v) requiring that PA services must be billed through the PA’s employer to be covered by Medicare Part B is only effective until January 1, 2022. After that date, PAs would be allowed to bill the Medicare program directly, which would align more with the rule for NPs and CNSs.

Check Out A Proposed Extension of Post-COVID Telehealth Options

In the CY 2021 PFS final rule (85 FR 84507), a 3rd category of criteria was created to temporarily add services to the Medicare telehealth services list, and these services would remain on the list until the end of the calendar year in which the PHE for COVID-19 pandemic ends. For CY 2022, CMS is proposing the telehealth services that have been added on a temporary basis remain covered until the end of CY 2023. This would permit more data to “be collected to gauge whether or not these services can be moved onto the list for permanent coverage as a Category 1 or 2 code,” according to Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Comment period open: CMS will accept comments on the proposed rule until 5 p.m. on September 13, 2021.

Note: >https://public-inspection.federalregister.gov/2021-14973.pdf?utm_medium=email&utm_campaign=pi+subscription+mailing+list&utm_source=federalregister.gov