Radiology Coding Alert

Plus, see how policy changes will impact your provider’s bottom line.

On Nov. 1, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a final rule for the 2020 calendar year (CY). In this final rule, CMS has solidified changes that are going to have an impact on physician reimbursement within the interventional radiology and nuclear medicine specialties.

In addition to these evaluation and management (E/M) code structure changes, the final rule also outlines changes involving the Quality Payment Program (QPP), Merit-based Incentive Payment System (MIPS), Advanced Alternative Payment Models (APMs), and more.

Read on to see what details might influence your provider’s reimbursement in the years to come.

Prep for Overhaul of E/M Guidelines

As per the recommendations of the American Medical Association (AMA), CMS has finalized its plans to make fundamental changes to the E/M coding structure for the 2021 CY. These changes, as outlined by the AMA, begin with the elimination of “history and physical as elements for code selection.” Furthermore, the AMA explains that “while the physician’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.”

This point leads you to another pivotal transformation for the 2021 E/M code set. This transformation involves a fundamental shift from the 1995/1997 guidelines. Beginning in 2021, CMS will allow for you to code E/M exclusively based on total time or medical decision making (MDM). With respect to MDM, this change means that the MDM level alone can determine the level to which you code a new or established patient visit.

Furthermore, you’ll also have the option to code to the highest E/M level using time as your only component. While the current guidelines allow for time reporting for E/M services in which counseling and/or coordination of care services consist of more than 50 percent of the visit, the new rules on time reporting will have no such restrictions. Instead, the practitioner will only be required to demonstrate the medical necessity of the visit in addition to documenting the total amount of time they spent with the patient. 

“I believe once the providers and coders become familiar with the new guidelines, it will be beneficial to all,” says Julie Leonard, CPC, CCS, CPCO, ACS-AN, RCC, CRCR, associate director at Kohler HealthCare Consulting in Woodstock, Maryland.

“While providers will have fewer documentation hoops to jump through, they will, however, need a very strong coding staff in order to capture all the revenue due to them with the add-on codes. Once providers and their staff understand the new guidelines and reimbursement structure, I believe it will be a revenue neutral change with less ‘administrative burden’ and, hopefully, more time with patients.” Leonard explains.

Coder’s note:  While these new guidelines will certainly appeal to some coders, you should know that you are still free to code patient visits based on the 1995/1997 E/M guidelines if you so choose.

1995/1997 E/M refresher: “As compared to the 1995 guidelines, CMS created the 1997 guidelines in order to give options across specialties to be able to document all levels of E/M services,” explains Marie Popkin, BS, CPC, project manager at Aviacode in Salt Lake City, Utah. “The 1997 guidelines offered specialty-specific exams as well as a multi-system exam in the hopes of leveling the playing field and addressing specialty society (e.g. ACR) concerns so that all providers were able to perform and document E/M services on a bell curve,” Popkin details.

Consider This New Prolonged Services Code

In addition to the changes outlined above, the 2020 final rule has revised its stance on some of the changes outlined in the final rule for the 2019 CY. While 99201 will become a deleted code in 2021, the proposal for blended payment rates for E/M levels 2-4 will not come to fruition. Instead, there will continue to be separate payments for each individual E/M level. Additionally, CMS proposed two new HCPCS Level II codes for reporting of prolonged or complex visits in the 2019 final rule. In place of these codes, CMS will introduce the following prolonged E/M services code:

• 99XXX (Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services))

In addition to the detailed code description, the AMA explains that this code should “only used when the office or other outpatient service has been selected using time alone as the basis and only after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded.”

Brace for Negative Financial Impact

Finally, it’s important to consider how Medicare Physician Fee Schedule (MPFS) value changes in the 2020 final rule will impact areas within the radiology specialty. The American College of Radiology (ACR) issues a warning that the payment changes to E/M services are going to have a negative impact on subspecialties within radiology:

• “CMS estimates a combined 8 percent decrease to radiology as a result of the necessary budget neutrality adjustment. However, The Moran Company, a prominent Washington-based health care research and consulting firm, estimates a nine percent reduction, translating to roughly $452 million a year, trended to $5.6 billion over a ten-year time period.”

The financial repercussions to the changes to the MPFS will certainly have a more profound effect on radiological subspecialties that involve office visits, such as interventional radiology. The ACR goes on to outline a concern regarding “the redistributive impact of revaluing the office/outpatient E/M visit code set for practitioners who do not routinely bill E/M visits.” While these changes will not be implemented until CY 2021, physicians should begin bracing for the financial impact sooner than later.