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Breaking: CMS backtracks on E/M pay changes, pivots to documentation overhaul

You can dismiss a lot of the controversial updates to office E/M services, such as blended payment rates, that drew an outcry from the medical community. But you’re now on the clock to get in line with far-reaching documentation changes for these oft-used services, according to the 2020 proposed Medicare physician fee schedule released today.
Overall, providers will see a modest boost to the conversion factor that, along with relative value units (RVUs), dictates pay rates across all services in the Medicare physician fee schedule. The conversion factor will rise to 36.0896 in 2020 from 36.0391 in 2019, according to the proposed fee schedule. The anesthesia conversion factor will rise to 22.2774 in 2020 from 22.2730 this year.
CMS nods to AMA’s E/M changes
CMS backpedaled on some of its more ire-inducing proposals related to the 10 E/M codes (99201-99215) that account for roughly 20% of Part B spending. Come 2021, you’ll find a separate payment rate for each of the E/M codes, instead of a single amount for Levels 2 to 4, as had been previously finalized. Note that the agency is not proposing any major changes to E/M pay rates for 2020.
CMS is aligning much of its forthcoming E/M policy with approaches that gained approval by the AMA’s CPT Editorial Panel earlier this year. That means CMS’ official policy is to significantly revise the E/M documentation guidelines by allowing providers to select a service based on medical decision-making or time. Providers would no longer have to factor in history and exam elements.
The federal agency announced it would adopt the new time ranges with the E/M codes as defined by the CPT Editorial Panel. You’ll also find one E/M code excised in 2021 – 99201 would be removed from the code set.
CMS also has accepted the updated E/M valuations put forth by the AMA’s RVS update committee (RUC). The financial takeaway remains unclear without further analysis. The new valuations, which would take hold in 2021, dramatically increase the work relative value units (RVU) for some of the E/M codes. For instance, the work RVUs for 99212 would rise from 0.48 to 1.18. Work RVUs for 99214, the most frequently reported office code, would increase from 1.50 to 1.92, according to the proposed fee schedule.
The agency is touting a net win when it comes to E/M payments. “The AMA RUC-recommended values would increase payment for office/outpatient E/M visits,” states a press release from CMS.
CMS announces new codes
Be on the lookout for more than 100 new CPT codes for E/M visits, procedures and radiology services in 2020, as well as 22 new G codes for a host of services, including new chronic care management (CCM) codes you’ll use in place of the CPT codes “until the CPT Editorial Panel can consider revisions to the current CPT code set.”
According to a review of Table 20: Proposed CY Work RVUs for new, revised and potentially misvalued codes, here are some changes coming your way in a few months. Note that any codes listed in will be placeholder codes. Watch for information about the final code sets later in the year.
  • More digital E/M services in 2020. The CPT editorial panel created three time-based codes for online digital E/M services in 2020 and CMS will cover the services. For example: 9X0X1 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes). The remaining two codes will be for cumulative services of 11-20 minutes and 21 or more minutes.
  • Grafting of autologous soft tissue and fat. You’ll have one new integumentary code to report grafting of autologous soft tissue and four new codes to report grafting of autologous fat harvested by liposuction. For example: 15X01 (Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate). An add-on code would be used for each additional 50 cc of injectate “or part thereof.”
  • Add-on codes for drug delivery devices. There will be three new add-on codes for the manual preparation and insertion of drug-delivery devices. For example: 206X0 (Manual preparation and insertion of drug-delivery device[s], deep [eg, subfascial] [List separately in addition to code for primary procedure]). You’ll have another three codes for the removal of the device, such as 206X4 (Removal of drug-delivery device[s], intramedullary [List separately in addition to code for primary procedure]).
  • Cardiovascular graft, repair and exploration. Watch for seven new codes in the cardiovascular system chapter of the 2020 CPT manual. New graft codes will cover ascending aorta and transverse aortic arch. Endovascular repair codes will allow you to report services of the iliac artery with or without a simultaneous repair of the aorto-iliac artery. Three codes will allow you to report exploration without surgical repair. For example: 35X01 (Exploration not followed by surgical repair, artery; lower extremity [eg, common femoral, deep femoral, superficial femoral, popliteal, tibial, peroneal]).
  • New nervous system codes. You will report lumbar punctures based on whether the service is performed with image guidance next year. In addition, you’ll have new codes to report injections and destruction of genicular nerves and nerves of the sacroiliac joint.
  • Myocardial imaging. Six new codes in the radiology chapter will allow you to report myocardial imagining with positron emission tomography (PET) and a concurrent CT scan next year. For example: 78X29 (Myocardial imaging, positron emission tomography [PET], metabolic evaluation study [including ventricular wall motion{s}, and/or ejection fraction{s}, when performed] single study; with concurrently acquired computed tomography transmission scan).
  • Electroencephalograms (EEG). There will be 23 new EEG codes next year. The majority of the new codes — 13 — describe services performed by technologists. Codes such as codes such as 95X21 (Electroencephalogram, continuous recording, physician or other qualified health care professional review of recorded events, complete study; greater than 60 hours, up to 84 hours of EEG recording, with video) describe services performed by physicians and other qualified health care professionals.
  • Chronic care add-on codes. Practices can get reimbursed for more than 20 minutes of time spent by clinical staff who are directed by a physician or qualified health care professional next year, thanks to a new system of primary and add-on codes. For example, the first 20 minutes of chronic care management would be reported with a code represented by GCCC1 in the proposed rule. An add-on code would be used for each additional 20 minutes of work. Two additional codes would allow practice to report 60 minutes of complex chronic care with a primary code and each additional 30 minutes of service with an add-on code.
Quality Payment Program updates
The biggest change in the Quality Payment Program (QPP) and the Merit-Based Incentive Payment System (MIPS) is prospective for 2021: A request for information (RFI) for a new MIPS Value Pathways (MVP) “framework” for the program, which would “connect quality cost, and improvement activities performance categories to drive toward value; integrate the voice of patients; and reduce clinician barriers to movement into advanced APMs,” according to the proposed rule. One example given of the highly simplified scoring is a “Preventive Health” pathway that could be met with six Quality measures, three Improvement Activities, all Promoting Interoperability measures and normal Cost scoring.
In 2020, meanwhile, things would not change much – though they would get more difficult. Scoring for MIPS is proposed at 30% for the Quality performance category, 30% for the Cost performance category, 25% for the Promoting Interoperability performance category and 15% for the Improvement Activities performance category. That is, Cost would go up 5% and Quality would decrease 5%.
The performance threshold that MIPS participants must reach is 45 points – 15 points more than the current 30. This is expected to go up another 15 points to 60 points the following year. The exceptional performance bonus threshold goes up to 80 points. The complex patient bonus and the small practice bonus remain at 5 points each.
The big news in the advanced APM model is the addition of an Aligned Other Payer Medical Home Model, with the “same characteristics as the definitions of Medical Home Model and Medicaid Medical Home Model, but it applies to other payer payment arrangements.”
Other news and highlights
  • One add-on E/M code remains. In other E/M news, CMS has opted to delete one of the two add-on codes it proposed to use for padding E/M payments. Instead, it will allow one code for all specialties: GPC1X (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious, or complex chronic condition).
  • Potentially misvalued codes. CMS proposes to examine four codes as potentially misvalued, including fine needle aspiration codes 10005 and 10021, 3D-rendering radiology add-on code 76377 and external counterpulsation therapy code G0166. Though codes 10005 and 10021 were added and revised, respectively, this year, a commenter stated that there is a “change in intensity” for the work of the codes “due to use of more complicated equipment and more stringent specimen sampling,” CMS states. A review this year of code G0166 did not take into account the total practice resources required to deliver the service according to an unnamed nominator, so CMS has agreed to re-evaluate it. CMS itself decided to examine the value of code 76377 after a 2018 review by the AMA RVS Update Committee (RUC) of a similar add-on code, 76376.
  • KX modifier returns for therapy services. Though the therapy caps were deleted by the Bipartisan Budget Act of 2018 (BBA), practices continue to have a $3,000 annual threshold for therapy services, CMS states. Once Medicare therapy payments exceed that amount, CMS requires the KX modifier be appended to therapy service codes to “confirm that the services are medically necessary as justified by appropriate documentation in the patient’s medical record,” the agency says. CMS imposes a single $3,000 threshold for physical therapy and speech-language pathology services and a separate $3,000 threshold for occupational therapy. In addition, CMS proposes to require the use of new modifiers to identify services furnished in whole or in part by a physical therapy assistant (modifier CQ) or occupational therapy assistant (modifier CO). The modifiers won’t trigger a reduction in payment just yet – that will begin in January 2022.
  • CMS seeks to integrate the Shared Savings program. In the long term, CMS wants to align the scoring methodology for its flagship accountable care organization (ACO) program with MIPS scoring, in part by allowing MIPS-eligible clinicians who are in MIPS APMs, such as Shared Savings ACOs, to report on MIPS quality measures as opposed to their current specific measure set. “We believe that using a single methodology to measure quality performance under both the Shared Savings Program and the MIPS [program] would allow ACOs to better focus on increasing the value of health care, improving care and engaging patients, and reduce burden as ACOs would be able to track to a smaller measure set under a unified scoring methodology,” states the proposed rule. In the short term, CMS proposes only small changes, such as removing one measure and adding another measure to the CMS Web Interface scoring.
  • Telehealth options proposed to treat opioid epidemic. There are three new, as-yet unfinished telehealth codes proposed for opioid-related activities: GYYY1 (Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month); GYYY2 (Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month); and GYYY3 (Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes). CMS proposes to offer this without the usual geographical limitations for telehealth.
  • Welcome new physician assistant supervision terms. Standing regulation requires that physician assistant (PA) services must furnish their services under the “general supervision of a physician,” as opposed to nurse practitioners (NPs) and certified nurse specialists (CNSs), who may furnish services “in collaboration” with a physician. To give PAs “greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice,” CMS proposes to relax its regulation on physician supervision of PAs so that “documentation in the medical record of the PA’s approach to working with physicians” would be sufficient to evidence supervision. CMS proposes this in response to “PA stakeholders,” who report that “PAs are now practicing more autonomously, like nurse practitioners (NPs) and clinical nurse specialists (CNSs), as members of medical teams,” CMS states.
Subscribers: Check upcoming issues of Part B News for more details on the proposed physician fee schedule and QPP.

Update: An earlier version of this blog post incorrectly stated that CMS would not cover EEG services performed by technologists. It also misstated the work RVUs tied to 99214. That information has been corrected.

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