As part of the CMS PFS Proposed rule for 2020, this summary includes most covered topics and codes utilized by our clients and subscribers. Although these policies are still in draft prior to the final rule being published early November, our abbreviated version will hopefully provide insight to upcoming changes in the physician fee schedule and telehealth approved services. Should you require additional details or contact information for CMS, we encourage you to visit the full document.
Telehealth
Although there were no requested additions to the telehealth list for 2020, CMS identified and is proposing to add services to address opioid disorder management to create a wider range of coverage options both in the office and via telehealth means. Note that these services require face-to-face interaction and can be delivered by individuals who are qualified to provide the services under state law and within their scope of practice “incident to” the services of the billing physician or other practitioner, as per CMS. Three new codes are being proposed:
● HCPCS code 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. (7.06 work RVU)
● HCPCS code 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. (6.89 work RVU)
● HCPCS code 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 (List separately in addition to code for primary procedure). (Add on code - .82 work RVU)
Supervision for PA’s
As rumored by lobbying societies, CMS is proposing to revise the regulation that Physician Assistant (PA) supervision would be purely governed and in accordance with State law as opposed to current Federal standards. In absence of a State Law, CMS rules would apply and stipulate that the supervision would be evidenced by documentation in the medical record as to the relationship of the PA working with the physician. The revision is intended to be more inline with current Nurse Practitioner laws that allowing them to practice more autonomously. This revision is also intended to create more access to medical care for the Medicare population.
Student Documentation
There’s been a long controversy regarding student documentation and how it impacts the payable portion of an E/M service. Recently CMS revised teaching physician guidelines to a more lenient standard, accepting student documentation as part of the record as long as the teaching (attending) physician reviewed, signed and agreed with the information. Lobbying groups representing Nurse Practitioners and Physician Assistants continued to push CMS to change the guidelines further to include other students as opposed to only medical students. CMS is proposing to generalize the guideline to include PA’s and ARNP’s students to document as part of the billable portion of the medical record (E/M visits) as long as its reviewed and verified by the licensed provider. This revision is intended to reduce the amount of documentation presently required under current guidelines.
Transitional Care Management
Since the creation of the TMC CPT’s, CMS has closely monitored the utilization of these codes against the volume of Medicare patient discharges (eligible for TMC). In a recent outside evaluation, CMS concluded transitional care codes are under utilized likely due to the administrative burden in documenting along with low reimbursement. Although there are a total of 57 CPT codes that bundle with transitional care services, CMS concluded that 14 of the CPT services do not overlap with the code intent or definition and therefore will be considered for unbundling for 2020. The table below represents the codes being considered for unbundling. Note these codes are categorized and have been evaluated by survey and public comment. Additionally, the RVU value is likely to increase - code 99495, moderate complex to 2.36 and 99496 high TMC 3.10. Definitions of the CPT codes are set to remain the same. TMC 99495 - services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit within 14 calendar days of discharge). TMC 99496 - with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least high complexity during the service period; face-to-face visit within 7 calendar days of discharge.
TCM - Services proposed to be unbundled
Chronic Care Management
CCM codes are a time-based, monthly, comprehensive care coordination services allowing providers to manage patients both face-to-face and non face-to-face with the help of clinical staff. CMS has monitored the use of these codes and determined that utilization has reached about 75% of what they anticipated under the PFS. Although the current use of these codes are positive result, they also feel this type of service is under utilized. For the upcoming year, they are proposing a new add-on code for chronic care management clinical staff time, each additional 20 minutes (work RVU .54). Rather than adding a new CPT, CMS is proposing four new G codes (GCCC1, GCCC2, GCCC3, GCCC4) to replace the current code set until they establish new utilization and definition. The current code definition for Complex Care Management is set to be revised and remove the requirement of ‘needing a substantial care plan revision’ as this language is implicit as part of complex medical decision making. The new definition for 99487 (GCCC3) would read - Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. (Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not reported separately – (1.0 work RVU). The new add-on code would be revised as GCCC4 and read - each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). (Report GCCC4 in conjunction with GCCC3). (Do not report GCCC4 for care management services of less than 30 minutes additional to the first 60 minutes of complex chronic care management services during a calendar month –(.50 work RVU).
A further revision defining a typical care plan is also being proposed to eliminate redundant language. CMS is also clarifying the fine print, that the elements of the care plan are suggested and not always required and would be at the discretion of the provider and specific to the needs of the patient.
A new subset of the CCM codes is also being developed to provide coverage for managing one chronic illness (vs. multiple) by specialists. Principal Care Management codes are defined as, GPPPI at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities – (1.28 work RVU).
HCPCS code GPPP2 would cover clinical staff time yet without the option of add-on time like the other CCM codes. Code definition is proposed to read - Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities – (.61 work RVU).
Evaluation & Management Services
The new and established evaluation and management CPT codes continue to take another shape as expected. In the previous payment model for 2021, CMS was ready to collapse levels 2-4 to a flat rate and introduce two new G codes, increasing payment for specialty complexity (per-visit resources), and time. Public commenters and stakeholders both felt this methodology was still overly complicated and not solving the problem of lessoning the burden of coding and documentation. The intent of the code set was revisited and yet another new method has been introduced and will further revise as below:
• 99201 will be deleted from the code set for 2020 as planned.
• Levels of service time increments and RVU values will change based on RUC recommendations (see table below).
• Elimination of history and exam as a factor in level of service for new and established E/M codes (this is unclear if this will span into other E/M categories beyond 99212-99205).
• Providers will have a choice of using time or medical decision to select a given level of service.
• A new prolonged code will be introduced (increments of 15 minutes) for time over and above the maximum code (99205 & 99215) for additional effort both face-to-face and non face-to-face time (.61 work RVU).
• Revision of new G codes for visit complexity (per visit resources).
Proposed CY 2021 total time and RUC recommended work RVU
Misvalued Codes
Although there are multiple CPT sections under payment revisions for 2020, Emergency Room E/M’s work values are proposed to take a slight increase from 2019 (CPT Codes 99281, 99282, 99283, 99284, and 99285). Based on the CY 2018 PFS final rule, CMS determined these codes might not be appropriately valued based on the full resources involved with patient care. For CY 2020, CMS is proposing the RUC-recommended work RVUs of 0.48 for CPT code 99281, a work RVU of 0.93 for CPT code 99282, a work RVU of 1.42 for 99283, a work RVU of 2.60 for 99284, and a work RVU of 3.80 for CPT code 99285. CMS will not be making a recommendation to increase the practice expense related to these five codes.