Gastroenterology Coding Alert

Plus: 2022 Final Rule also provides insight into split/shared visits.

Gastroenterology practices may find a few silver linings in the 2022 Medicare Physician Fee Schedule final rule, which CMS issued on Nov. 2. While pay for GI specialists is expected to fall by as much as 10 percent in the new year absent Congressional action to change this scenario, some positives are expected to hit during 2022.

Check out a few key policy changes that may impact your bottom line:

Find New Coinsurance Amounts for Colorectal Screenings That Turn Diagnostic

GI practices have long faced confusion from patients who presented for screening colonoscopies, which have no coinsurance. However, if the physician found a polyp during the screening and removed it, the colonoscopy was then considered diagnostic, which meant that coinsurance costs kicked in, surprising many patients who expected to pay nothing for the service.

CMS aims to fix that issue by phasing out these coinsurance costs over the next several years. “For services furnished on or after January 1, 2022, the coinsurance amount paid for planned colorectal cancer screening tests that require additional related procedures shall be equal to a specified percent (i.e., 20 percent for CY 2022, 15 percent for CYs 2023 through 2026, 10 percent for CYs 2027 through 2029, and zero percent beginning CY 2030) of the lesser of the actual charge for the service or the amount determined under the fee schedule that applies to the test,” CMS says in a fact sheet about the final rule.

This should allow GI practices to face far fewer confused patients following these diagnostic services. “Don’t forget to add modifier PT (for Medicare) or 33 (for commercial payers) to identify these as preventive services,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

Telehealth Expansion Includes E/M Codes

CMS is continuing to monitor a variety of codes that it temporarily added during the COVID-19 public health emergency (PHE) to its Medicare telehealth services list. Fortunately, the rule does finalize keeping “certain services” on the list through Dec. 31, 2023, to give CMS more time to evaluate the services, the fact sheet indicates.

This includes the office E/M services (99202-99215), among several other codes. CMS aims to analyze data through 2023 to evaluate the benefits of providing these services via telehealth before deciding whether they could potentially be added to the permanent list of approved telehealth services.

Understand Changes to Split/Shared E/M Services

If your GI specialist performs split/shared visits, you may find some of the 2022 provisions of interest. “CMS is proposing to continue its current policy allowing billing of certain ‘split’ or ‘shared’ E/M visits by a physician, when the visit is performed in part by both a physician and a non-physician practitioner (NPP), who are in the same group and the physician performs a substantive portion of the visit,” explains Michael A. Granovsky, MD, CPC, FACEP, president of LogixHealth, a national coding and billing company. “CMS is limiting split or shared to E/M codes only, not procedures.”

Plus, CMS offers other insight on split/shared services in the rule, including how time factors into the E/M visits, reporting for new and established patients, modifiers, documentation, and codification of the revised policies.

Important: In a new definition, CMS explains that whoever provides the “substantive portion of the visit” bills for the services — whether it’s the physician or the NPP. “For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time),” CMS says in the fact sheet. But, “by 2023, the substantive portion of the visit will be defined as more than half of the total time spent.”

Table 26 from the final rule details the possibilities of determining the substantive portion of different visit types. “You can expect pushback from many physician groups, who will find it much more burdensome to bide by this new definition of substantive, and will be pushing to retain medical decision making as an option,” Littenberg said.

Physician Assistants Can Directly Bill Medicare

You may remember that Section 403 of the Consolidated Appropriations Act, 2021 (CAA) mandated the removal of the federal requirement to only pay physician assistants’ (PAs) employers or independent contractors for services provided by PAs.

Starting on January 1, 2022, “PAs may bill Medicare directly for their professional services, reassign payment for their professional services, and incorporate with other PAs and bill Medicare for PA services,” CMS’ fact sheet about the final rule says.

Vaccination Pay May Rise

Commenters on the proposed rule highlighted the “complex landscape” on vaccinations that emerged during the pandemic and the critical importance of preventative immunizations, the final rule says.

Due to the outpouring of public input, “effective January 1, 2022, CMS will pay $30 per dose for the administration of the influenza, pneumococcal and hepatitis B virus vaccines,” the agency says. On top of that, the current payment rate for COVID-19 vaccines will remain status quo at $40 through the duration of the PHE. After the PHE ends, CMS plans to align the COVID shot rates with other Part B vaccine rates, the fact sheet indicates.

Teaching Physician Payment Subject to Stricter Criteria

To better align with the CY 2021 changes to office/outpatient E/M visit codes, CMS revised its teaching physician policies for selecting the correct E/M visit levels. “When time is used to select the office/outpatient E/M visit level, only the time spent by the teaching physician in qualifying activities, including time that the teaching physician was present with the resident performing those activities, can be included for purposes of visit level selection,” notes the fact sheet.

“CMS clarifies that Medicare will not pay teaching physicians for shared services unless the physician exercises full, personal control over the portion of the case for which the physician is seeking payment,” Granovsky explains.

Why? “Under the primary care exception, time cannot be used to select visit level. Only MDM [medical decision-making] may be used to select the E/M visit level, to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services,” CMS says.

Resources: Find the rule at https://public-inspection.federalregister.gov/2021-23972.pdf.