Physician practices have been trying to keep up with all of the recent changes that have been made to the Evaluation and Management Codes over the past 2 years in the office setting.
In 2021, AMA CPT® Editorial Panel approved and published new documentation guidelines for Office and Other Outpatient Evaluation and Management (E/M) CPT® codes (99202-99215, deleting 99201) and their code descriptors and documentation standards that directly addressed the continuing problem of administrative burden for physicians in nearly every specialty, across the country.
After these revisions were implemented, in 2021, it has been challenging for physicians to manage two sets of documentation rules, since the office visits were the only rules updated and the 1995/1997 documentation guidelines were still in place for all hospital E/M services.
However, announced this past week, is some good news. The CPT® Editorial Panel has now approved, for 2023, additional revisions to the rest of the E/M code section. These revisions seek to provide continuity across all the E/M sections, by allowing for the revisions implemented in the E/M office visit section in 2021 to extend to all other E/M sections beginning January 1st, 2023.
Medicare (CMS) also has a stake in this update and published their version of the new updates in their recent (July 7th) newsroom article.
As part of the ongoing updates to E/M visits and related coding guidelines that are intended to reduce administrative burden, the AMA CPT® Editorial Panel approved revised coding and updated guidelines for Other E/M visits, effective January 1, 2023. Similar to the approach we finalized in the CY 2021 PFS final rule for office/outpatient E/M visit coding and documentation, we are proposing to adopt most of these changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) effective January 1, 2023. This revised coding and documentation framework would include CPT code definition changes (revisions to the Other E/M code descriptors), including:
- New descriptor times (where relevant).
- Revised interpretive guidelines for levels of medical decision making.
- Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services).
- Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam).
We are proposing to maintain the current billing policies that apply to the E/Ms while we consider potential revisions that might be necessary in future rulemaking. We are also proposing to create Medicare-specific coding for payment of Other E/M prolonged services, similar to what CMS adopted in CY 2021 for payment of Office/Outpatient prolonged services.
The following is also a summary of some “key” revisions to the E/M code descriptors and guidelines for 2023 will be.
The CPT® Editorial Panel worked to again, create revisions to the E/M code descriptors and guidelines that met their objective to decrease the administrative burden of excessive documentation whenever possible. We hope as physicians continue to embrace these changes, that it will decrease the need for audits, through the expansion of fundamental definitions of E/M encounters, and by focusing on patient care, and not the unnecessary and potential non-contributory work of cut and paste, templated items.
We will be presenting Educational Webinars OnDemand and Live on E/M updates to make sure everyone is up to speed on their updates prior to implementation, 1-1-2023. These will be scheduled this fall. Continue to visit our website for an updated educational calendar.
The PHE was renewed another 90-days effective April 16th, 2022, but what 1135 waivers expired?
As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, on this date and after consultation with public health officials as necessary, I, Xavier Becerra, Secretary of Health and Human Services, pursuant to the authority vested in me under section 319 of the Public Health Service Act, do hereby renew, effective April 16, 2022, the January 31, 2020, determination by former Secretary Alex M. Azar II, that he previously renewed on April 21, 2020, July 23, 2020, October 2, 2020, and January 7, 2021, and that I renewed on April 15, 2021, July 19, 2021, October 15, 2021, and January 14, 2022, that a public health emergency exists and has existed since January 27, 2020, nationwide.
As expected, the COVID-19 PHE (Public Health Emergency) has been extended another 90-days, effective April 16th, 2022. This means that “most” waivers under the 1135 CARES Act of 2020 will continue to stay in effect through this period, through July 19th, while others are winding down.
CMS has already alerted providers that many nursing home compliance standards will phase out, while still protecting those residents.
During the PHE, CMS used a combination of emergency waivers, 1135 Regulations, and sub regulatory guidance to offer healthcare providers the flexibility needed to respond to the COVID-19 pandemic. CMS is ending specific waivers to two groups: One will end 30-days from the issuance of the new guidance and the other group will terminate 60-days from issuance.
The good news is that access to certain services, primarily Telehealth Coverage, continues not only through July, under the waiver 1135 flexibilities, but also with the Consolidated Appropriations Act of 2022 Congressional extension, it will continue to be covered for 151 days after the PHE ends. But what does that mean exactly and are there any variables that need to be addressed?
Telehealth with the patient using their home as the originating site, will continue to be allowed when billing for office visits when an audio and video connection exists. Audio only visits billed with telephone CPT® codes, will continue for another 90-days as well.
However, there was a new PHE Fact sheet that was published on April 7th, (see link to this sheet below), that addressed some compliance issues that have not been addressed during the PHE, and this could be problematic for many physician practices.
The HHS Secretary has authorized 1135 waivers that allow CMS to waive the Medicare requirement that a physician or non-physician practitioner must be licensed in the State in which s/he is practicing for individuals for whom the following four conditions are met:
In addition to the statutory limitations that apply to 1135-based licensure waivers, an 1135 waiver, when granted by CMS, does not have the effect of waiving State or local licensure requirements or any requirement specified by the State or a local government as a condition for waiving its licensure requirements. Those requirements would continue to apply unless waived by the State. Therefore, in order for the physician or non-physician practitioner to avail him or herself of the 1135 waiver under the conditions described above, the State also would have to waive its licensure requirements, either individually or categorically, for the type of practice for which the physician or non-physician practitioner is licensed in his or her home State.
Many practices made assumptions that if CMS and Medicare said you can do it, that this was a blanket waiver for all states and all payers. Not true.
No, a PHE declaration does not waive or preempt state licensing requirements. States determine whether and under what circumstances a non-Federal healthcare provider is authorized to provide services in the state without state licensure. As discussed in response #5 above, when the Secretary issues an 1135 waiver, the Secretary may waive Medicare, Medicaid or SCHIP requirements that physicians and other health care professionals hold licenses in the State in which they provide services. This would be for Medicare, Medicaid or SCHIP reimbursement purposes only, and would apply only if the physicians or other health care providers have an equivalent license from another State (and are not affirmatively barred from practice in any State in the emergency area).
Again, these clarifications were made on the PHE, not included in the COVID-19 FAQ Sheets. This may be confusing for some practices, as again assumptions made where not clear. I would strongly urge physicians who treated patients during the PHE, via Telehealth in other states, to check with their personal liability insurance coverage and their healthcare attorney to make sure no infractions of the rules were made. Also, any retired physicians that were allowed, again, under the COVID-19 waivers, to come out of retirement and see patients via Telehealth for Medicare, did your state allow this for private insurance and self-pay patients? Many state level PHE Waivers expired in 2021, and early 2022.
We strongly urge clients and physicians to check with their liability/malpractice insurance and their state legislature rules on Telehealth, and what is allowed for physicians continuing to cross state lines with virtual care. Protect yourself and your practice by being informed. If you need any assistance finding this information, please use our “Contact Us” tab to engage services.
As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, on this date and after consultation with public health officials as necessary, I, Xavier Becerra, Secretary of Health and Human Services, pursuant to the authority vested in me under section 319 of the Public Health Service Act, do hereby renew, effective October 18, 2021, the January 31, 2020, determination by former Secretary Alex M. Azar II, that he previously renewed on April 21, 2020, July 23, 2020, October 2, 2020, and January 7, 2021, and that I renewed on April 15, 2021 and July 19, 2021, that a public health emergency exists and has existed since January 27, 2020, nationwide.
If you have heard the acronym HIPAA thrown around a lot lately, you are probably thinking, “Do I know what HIPAA means?”. So many are throwing that term around in the falsehood that their legal or privacy rights are being violated in some way as more and more companies are requiring COVID-19 vaccines to secure employment, to stay employed, and now, let’s face it to enter certain public places or to travel.
Well first, let’s clear up the confusion.
The first thing you should know about HIPAA is that it’s HIPAA, not HIPPA. There is only one P, and that P doesn’t stand for “privacy.”
“People make up what that acronym stands for,” Deven McGraw, co-founder, and chief regulatory officer of the medical records platform Citizen and former deputy director for health information privacy at the Department of Health and Human Services (HHS) Office for Civil Rights (OCR), had stated in a recent interview.
“More often than not, [they think it’s] Health Information Privacy Protection Act: HIPPA. Yeah, that law does not exist.”, McGraw said.
But now, we see the media asking government officials like Georgia Rep., Marjorie Taylor Green, or Dallas Cowboy quarterback Dak Prescott, or New England Patriots quarterback Cam Newton, all ‘invoke” their HIPAA rights. Green even claimed, more than once, that just asking the question was somehow a “violation of her HIPAA rights”. Incorrect. As more and more employers and healthcare entities and even schools, mandate that employees and students get vaccinated, we need to make sure we are clear on not only what HIPAA is, but how it is applied.
So let’s get one big question out of the way first:
Nor is it a HIPAA violation for them to ask for proof that you have been vaccinated, though many people seem to think that providing or even soliciting any sort of health information automatically becomes a HIPAA issue.
Employers do have to keep their employees’ vaccination statuses confidential, but that’s because of the Americans with Disabilities Act — not HIPAA, which, again, doesn’t apply here.
Both the misspelling and the widespread belief that HIPAA confers a strict set of privacy protections to any health data — and that everyone is subject to those laws — are common, although frustrating mistakes: Most patients only come across the term HIPAA, when signing the notice of privacy practices that the law mandates their health care providers have them sign. Plus, most people consider their health information to be very sensitive and assume their physicians and lawmakers have put the appropriate guardrails in place to keep it as private as possible. But HIPAA’s privacy rules are more limited than many may realize.
What is not well understood about HIPAA, is its limits. It’s very specifically a law that regulates information that is collected because a person is seeking health care.
Normally, the misunderstanding would be just an annoying misstep, but the pandemic has helped bring health privacy issues to the fore. As with many other things over the past year, we’ve moved many of our health interactions to the virtual space, and with the CMS 1135 Waiver flexibilities, under the C.A.R.E.S. Act, some of those interactions may not be covered or protected by HIPAA, but many people simply assume they are.
For example: If you are participating in a Telehealth encounter with your physician, and you are using a smartphone application, such as FaceTime or Skype, as allowed under the Waiver 1135 during the PHE, these platforms are not HIPAA protected, and your physician must inform you of that potential risk of breach of your personal health information before you choose to continue with your visit. This also has to be well documented in the encounter that you were informed, in the way of consent.
What has happened since about 2-3 months into the pandemic, is that it has become increasingly politicized, and many people have cited “HIPAA rights” as an excuse to get out of mask mandates and to declare vaccine passports and mandates to be illegal. Neither of these assertions is true, but that hasn’t stopped many people from making them — even though using them to avoid public safety measures could be harmful to everyone. People have such a high level of confidence believing misinformation, that it is out of control in the COVID era.
The perception that HIPAA is solely a health privacy law that everyone is subject to has become so common that there’s a massive amount of confusion about who and what HIPAA applies to; that the sheer volume of bad information about it is nearly insurmountable.
Social media platforms have been a problem when attempting to give credible information. Trying to get people to understand what a “Covered Entity” or “Business Associate” is in 280 characters is not an easy task. These platforms can write the words, but of course, people will believe what they want, and if it is contrary to what they want it to mean, then the platform doesn’t lend itself well to a considered nuanced discussion.
So what does that one P stand for if not privacy? Portability.
HIPAA is short for the Health Insurance Portability and Accountability Act. The 1996 law’s origins lie in creating federal standards for digitizing medical claims data and records (“accountability”) and allowing employees to have health insurance coverage, including for preexisting conditions, when they changed jobs (that’s the “portability”) — rights they did not have before the Affordable Care Act.
The privacy provision, that most of us associate HIPAA with today, wasn’t the focus of the law at the time. When Congress passed this law, they knew on some level, that there was going to be a massive digital transition to our health data in the future, and there might need to be privacy protections for that.
It took a few years to work those protections out, so HIPAA’s privacy rules weren’t issued until the end of 2000, and didn’t fully take effect until 2002. There was a recent update in 2013.
HIPAA only applies to what is called “Covered Entities.” Those are, essentially, health care providers (doctors, hospitals, and pharmacies, for instance), health insurers, and health care clearinghouses (which process medical data). It also covers their “business associates,” or contractors who have to handle medical records in some way to do work for those covered entities. Those parties are required to follow certain protocols to keep your protected health information secure and private, especially in the digital transfer of patient health information.
This is why healthcare providers or insurers might require patients to communicate with them through secure, HIPAA-compliant channels and patient portals, or take other steps to verify a patient’s identity before discussing protected health information with them. HIPAA’s privacy rule also requires that health care providers give the patient, a notice of their privacy practices, and allow patients to access their medical records. A lot of HIPAA complaints from patients aren’t about privacy violations but about lack of access to medical records, which created the 21st Century Cures Act, to shift that focus to the OCR – Office of Civil Rights.
It’s important to note that medical privacy didn’t begin with HIPAA, and it’s not the only health privacy law out there. The concept of doctor-patient confidentiality has existed for a long time — it’s part of the Hippocratic Oath (which is not a law) — and that trust is a necessary part of good medical care.
Patients’ have to feel a level of comfort that if they tell their physician some very private, and secret things, that they will be kept that way, and this allows a physician to give the patient the right care and diagnose them properly.
At the same time, many people freely give away their health information to all kinds of places and platforms and to people who have no real legal obligation to keep that information private or secure. With the internet and social media, this is happening more than ever.
Consider this, If you’re recording your steps on a Fitbit or you’re using a nutrition app, that’s not going to be covered by HIPAA. That is not a HIPAA entity and can use that information to market to you athletic shoes or equipment, supplements, etc.
That amazing massage therapist appointment you Tweeted about? Your vaccine card Instagram selfie? Your membership in a Facebook support group for people who have cancer? The period tracker app on your phone? The heart rate monitor on your wrist? Browsing WebMD for information about your recent COVID-19 diagnosis? The mail-order DNA test? The Uber trip you took to the emergency room? That is all health information, most of it is directly tied to you, and it can be sensitive, but none of it is covered by HIPAA (unless protected health information is shared with a covered entity, like a hospital or physician who ordered it, requested it, and asked you to deliver it that way. Even then, it is sketchy.
And then we’ve got the organizations that handle health data but aren’t covered by HIPAA, including most schools, law enforcement, life insurers, and even employers. They may be covered by other privacy laws, but HIPAA isn’t one of them.
A big hiccup to all this is that we are still under the Federal PHE, (some states have let their PHE expire). So, some things that are covered by HIPAA have been given a temporary enforcement waiver due to the pandemic. The Office of Civil Rights will not be enforcing its rule requiring health care providers to use HIPAA-compliant portals for telehealth (as long as patients were informed), nor will it require covered entities to use HIPAA-compliant systems to schedule vaccines — an issue that arose when some health services’ sign-up portals crashed and the services turned to the event scheduling platform, Eventbrite. Eventbrite is a good service for getting a lot of people signed up for an event in high demand, but it’s not HIPAA compliant, and posts events on a public forum.
The Office of Civil Rights (OCR) has stated that that enforcement discretion will remain in effect “until the Secretary of HHS determines that the public health emergency no longer exists, but again, patient’s need to be informed of this security risk, as outlined in the CURES Act and the CMS FAQ rules sheets.”
Understand that if you go to Starbucks (not a covered entity) and refuse to wear a mask because you say you have a health condition, it is not a HIPAA violation if the barista asks you what that condition is, nor is it a HIPAA violation if Starbucks refuses service to you. They are a private business and not a HIPAA entity and can enforce any rules they want that they feel protects public safety and their business, as long as it is not discriminatory to a protected class (i.e race, religion, gender, disability, etc).
If your doctor were to walk into that Starbucks and broadcast your health information to anyone within earshot without your permission, that would be a HIPAA violation. It would also be a good time to consider changing doctors. Fortunately, HIPAA allows you to request your medical records and bring them to a new provider. And if someone else happened to record your doctor’s outburst and put it on TikTok, that’s not a HIPAA violation, even though it does include information that was once protected by HIPAA.
Additionally, someone asking if you’ve been vaccinated is not a HIPAA violation. It’s not a HIPAA violation for anyone to ask about any health condition you may have, though it might be considered rude. A business requiring you to show proof that you’ve been vaccinated before you can enter is not a HIPAA violation. Your employer requiring you to be vaccinated and show proof before you can go to the office is not a HIPAA violation. Schools requiring that students get certain vaccinations before they’re allowed to attend is not a HIPAA violation.
Oh, and vaccine passports — which the Biden administration has already said, it has no plans to mandate, but could change in the future – are also not HIPAA violations.
Look at certain health records apps that are all the rage now, like New York’s Excelsior Pass (ePass) to use it, you are voluntarily giving the app permission to access your health records, and, as the app’s disclaimer clearly states: “[T]he website is not provided to you by a health care provider, so, as such, you are not providing protected health information for health care treatment, payment, or operations (as defined under Health Insurance Portability and Accountability Act (HIPAA)).” Does anyone read the fine print anymore?
So HIPAA isn’t the all-inclusive health privacy law so many people assume it is, but that mass assumption suggests that such a law is both wanted and may be needed. HIPAA has a lot of gaps that a privacy law can and should fill. The pandemic has only made this more apparent.
What we need is for Congress to pass a comprehensive privacy law that sets limits on what the companies can use this data for, how long they can keep it, who they can disclose it to, and doesn’t put the burden of dealing with that on the individual.
Rep. Suzan DelBene (D-WA) is one of several lawmakers who have pushed for better health privacy protections during the pandemic, including as a co-sponsor of the Public Health Emergency Privacy Act, a bill that was introduced in both houses of Congress in 2020 and reintroduced in early 2021. Its premise is that it would protect digital health data collected to stop the pandemic (for instance, by contact tracing apps or vaccine appointment booking tools) from being used for unrelated purposes by the government or private businesses.
HIPAA provides some protections for our health information, but technology has advanced must faster than our laws.
In the meantime, if you have any question whether or not you or another business or person is a “Covered Entity” and needs to comply with HIPAA standards, CMS has a tool to help health care providers and organizations determine whether or not they are considered a covered entity. The link is included below. Also, join me (Terry Fletcher), and Healthcare Attorney, and fellow NSCHBC member, Amanda Waesch for our October 12th, episode of the NSCHBC Edge podcast. We will be discussing this very topic and diving into the legalities of these mandates and how they will affect healthcare providers soon.
You can also listen to Terry each week on her CodeCast Podcast found on all downloadable platforms.
As a result of the continued consequences of the Coronavirus Disease 2019 (COVID-19) pandemic, on this date and after consultation with public health officials as necessary, I, Xavier Becerra, Secretary of Health and Human Services, pursuant to the authority vested in me under section 319 of the Public Health Service Act, do hereby renew, effective July 20, 2021, the January 31, 2020, determination by former Secretary Alex M. Azar II, that he previously renewed on April 21, 2020, July 23, 2020, October 2, 2020, and January 7, 2021, and that I renewed on April 15, 2021, that a public health emergency exists and has existed since January 27, 2020, nationwide.
As we are now well into 2021, and over 12-months from the beginning of the first announced PHE (public health emergency), the past year has been a whirlwind of medical practices having to pivot to a new delivery of care, Telemedicine. This platform also referred to as Telehealth, has seen an uptick of visits in the 80-90% range of overall patient outpatient encounters according to MGMA.
CMS and other Commercial payers adjusted their coverage policies to allow for these types of visits, virtual and remote care when the patient is in their home, and their care is delivered by an audio and video platform, or through a telephone call. The reason that the insurance payers have allowed Telehealth during the PHE, is to limit the spread of COVID-19 and to protect the most vulnerable to the virus, but still allowing for needed care.
Many pro-Telehealth entities and providers are advocating to continue with the current, PHE rules of Telemedicine delivery once the PHE end, but as the OIG stated in their 2021 Work Plan, assess the overall effectiveness of Telehealth and ensure it is not just a convenience over a medically necessary delivery of medicine.
With the 2021 Medicare PFS (Physician Fee Schedule) changes and the CMS C.A.R.E.S act Flexibility’s set to roll back once the PHE ends, what can you do now in your practice to prepare for potential changes in reimbursement and coverage?
The first thing to realize is, that the PHE is temporary.
Yes, the COVID-19 virus challenges may take us through the end of 2021 to slow, and as vaccines increase, there is a light at the end of the tunnel, but the PHE, in the truest of definitions, will end at some point. That will mean regulations will be rolled back; to what extent we are not completely sure, but we have the Social Security Act and CMS rules to follow and that cannot be changed unless an act of Congress does so and that takes months, even years to make happen.
In the CodeCast podcast, last November and December, I discussed this very question and how practices should handle the potential transition, once the PHE ends, also what is being audited since Telehealth services are now on the OIG Workplan for 2021. But the question, “Are you all-in on Telehealth or is this a stopgap during PHE?” has to be answered first.
How much is your practice willing to spend to make sure that your patients have equal access to an audio and video platform? Many patients still do not have the high-speed internet needed to engage in Telehealth services, and when the PHE ends, non-HIPAA protected platforms such as FaceTime and Skype will no longer be an option.
Also, one of the flexibility rules that will be rolled back to the original Telehealth regulation will be the “individual receiving the service must be located in a telehealth originating site”. This means, the patient’s home will not be an option, once the PHE ends unless the patient qualifies in an HPSA (Health Professional Shortage Area) area or is a mental health patient.
Under the CARES Act, Congress gave CMS the ability to waive the geographic location requirement during the COVID-19 PHE.
The current Public Health Emergency (PHE) is in effect through April 22, 2021, per www.phe.gov for certain RPM services through December 31, 2021 (the year in which the PHE ends).
CMS, in the 2021 Final Rule, grouped the Telehealth services into three categories as we navigate this next year during the PHE:
Category 3 codes, such as physical and occupational therapy, initial hospital care discharge day management, inpatient neonatal and Pediatric critical care, initial and subsequent may not remain after the PHE expires. CMS has also been clear that audio-only phone call codes, 99441-99442, will not be covered under the Telehealth provision, once the PHE ends, and created a new G-code G2252 as an 11-20-minute audio-only code cross-walked to code 99442 to allow for an encounter when the physician may not be able to have an encounter to visualize the patient.
We cannot foresee the future on where Telehealth is going, but as one recent CMS “Office Hours Calls” pointed out when asked about the patient’s home as a valid place of service (POS) continuing after the PHE ends, they stated “No”. Again, only for HRSA (rural Health Professional Shortage Area) or MSA (Metropolitan Statistical Area) patients, or for patients suffering from mental illness was that a possibility. That is a huge determining factor when a patient chooses to use Telehealth or not.
If they have to leave their house anyway to transport to an “approved” originating site, such as a hospital, physician’s office, or another medical facility, they might as well keep driving to their physician’s office if that is the only option. Commercial plans may allow more flexibility on this delivery of medicine since they are contract providers and can call their shots when it comes to coverage.
The healthcare consultants at NSCHBC want to advise our clients, and potential clients to do their due diligence, and determine if you will continue with offering Telehealth in the future in your practice, and what will be your business model for that offering? Most practices have said they will offer it, but it would be a good idea to survey your patients to find out what they would do if suddenly their home was not an approved site to receive Telehealth benefits.
Would they pay cash? Would they still engage? Or would they go back to the in-person care? A question for providers that have been using the PHE allowed smartphone device platforms such as FaceTime and Skype, “Will you invest in additional software to be HIPAA compliant?” These are questions to ask, as you prepare for another pivot in your delivery of medicine once the PHE ends.
Stay tuned to this ever-changing virtual delivery of medicine and how, after PHE, the reimbursement process will be handled and how it will affect continued payer coverage in medical practices.
Today, the Centers for Medicare & Medicaid Services (CMS) issued guidance on Health and Human Services (HHS) Secretary Alex Azar’s waiver authority that broadens access to Medicare telehealth services. Effective March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, CMS will:
Expect more updates on this in the days and weeks ahead!
Please join Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM for an on-demand webinar on how to implement these changes and more.
You can register for this session by clicking the button below and scrolling to the down to the register section.
Note: This webinar has been updated and replaced by Telehealth OnDemand Webinar: CMS and Other Payer Updates which you can register for at the same link below.
AMA is on track to revise E/M codes and set new documentation guidelines. What was considered to only target the Office and Other Outpatient visits, has now been expanded to impact the entire E/M section of CPT®.
The AMA’s CPT® Editorial Panel approved many changes to the Evaluation and Management documentation and coding guidelines. If finalized, the changes will shift the way medical practices select codes for both office and facility visits as soon as January 2021.
Deletion of level 1 office new patient E/M code 99201.
(For Medicare, claims for code 99201 represented only 0.15% of all 266 million inpatient E/M claims in 2017, when it had a 37% denial rate (versus an overall E/M denial rate of 5%).
AMA’s Panel agreed to the removal of history and exam as key components for selection of the E/M service level. This means that the history and exam would not be used to “score” the visit for an audit. However, the practitioner would be required to document that these elements were performed in order to report an office visit code. Evidence of the history and exam should still be part of the documented record.
Practitioners would select E/M codes based on either 1) the level of medical decision making (MDM) or 2) the total time spent performing the service on the day of the encounter. (Note: “time” will limit you on how many patients you can see per hour).
Total time would include “total time spent on the day of the encounter,” instead of total face-to-face time of the visit.
A major overhaul of the MDM documentation guidelines to emphasize complexity of the conditions being addressed in place of the number of diagnoses reported.
Within the office and outpatient E/M guidelines, MDM section title updates would include:
AMA proposes to make some changes to other E/M codes; for example, they would revise prolonged E/M or psychotherapy service codes 99354 and 99355, which currently say “in the office or other outpatient setting,” to “exclude reporting of Office and other Outpatient Services codes. Also, a new 99XXX code would be added to “report prolonged office or other outpatient E/M services.” Guidelines would be revised.
AMA proposes to add guidelines for reporting time “when more than one individual performs distinct parts of an E/M service.” This will need to be clarified as to what constitutes the clinical team as part of the encounter.
AMA proposes to add a Summary of Guideline Differences table to denote the differences between the different sets of guidelines, as well as new definitions of terms, a new MDM table, and definitions of total time associated with outpatient E/M codes. The CPT editorial panel is seeking comments through March 25. Details are available on the AMA CPT website.
(A version of this article was referenced from Part B News)
There seems to be a lot of confusion that the E/M codes and levels are changing in 2019. This is NOT accurate. The changes to the levels of E/M’s and reimbursement will not occur until 2021.
Here is what is happening in 2019. Everything is spelled out in this link.
The four bullet points below for 2019 and 2020 really do not reflect anything different from what is already required and has always been required, except for the first bullet. (See highlights below.)
For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. For CY 2019 and beyond, CMS is finalizing the following policies:
In what is being reported as the biggest change of its kind in more than two decades, the Centers for Medicare & Medicaid Services (CMS) plans to redefine the documentation requirements for evaluation and management (E&M) coding in 2019, along with flattening payments for new and established patient office visits to a single pay system. The proposal offers $93 for established office visit codes (99212-99215) and $135 for new patient visits (99202-99205).
CMS is proposing to forego the 1995 and 1997 guidelines for what is being reported as a “simpler model” that will eliminate the need to re-document redundant information from prior visits and instead focus on medical decision-making. CMS is also proposing to blend patient E&M encounters into one specific relative value unit (RVU) because in their opinion, documentation is based on the ability of providers to get into their electronic medical records (EMRs) to find additional information other than what was noted.
But what is missing in all this is the reality of the reimbursement concerns, especially for specialty physicians who are taking care of sicker patients who need more time, effort, and higher levels of care to manage their complex issues.
This proposal will in effect penalize those physicians in specialties such as oncology (7 percent reduction), neurology (7 percent reduction), cardiology (3 percent reduction), pulmonary (3 percent reduction), rheumatology (7 percent reduction), and nephrology (3 percent reduction), to name a few. This does nothing to cut spending under the Medicare program, but more redistributes money among physicians.
Instead of the American Medical Association (AMA), in conjunction with Medicare, adopting a new code set, CMS is attaching the same RVU to the level 2 through 5 codes for both new and established patients, which creates the same payment amount. Most of the impact will be focused on 99214 and 99215, with a 15 percent cut of about $16-$23. These codes are about 89 percent of all allowed services, according to CMS data, and practices routinely billing the 99204 new patient code would see a 13 percent decrease in reimbursement. Your E&M profile would determine if you are in the “win” or “lose” column with this proposal.
Modifier 25 could be used as a reduction edit for CMS, not protection for your E&M encounters.
Also included in the 2019 proposal is the multiple payment reduction proposal. How many times do you place a modifier 25 on an E&M service when providing a second service (i.e., a skin tag removal, an injection, a diagnostic test, etc.) on the same day? Often done for patient convenience and for physician efficiency, CMS is proposing to reduce reimbursement for such services by half (the national equivalent of $47-$68 on a sick visit encounter). This reduction model previously has only been applied to surgical procedures, when multiple procedures are performed during the same surgical event. The impact of this change on physician office-based and outpatient-based services would be dramatic.
Modifier 25 serves as a true indicator of a:
Significantly, separately identifiable evaluation and management service above and beyond the pre-service workup of a procedure, performed on the same day by the same physician
As such, it should remain untouched to ensure that all Medicare beneficiaries are provided appropriate care and evaluations and are not forced to make repeat visits, resulting in increased co-payments and out-of-pocket costs, not to mention unwarranted, burdensome, and expensive travel back to the office!