Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 15, 2021 PDF

Plus: Feds solidify E/M payment and documentation updates.

In its latest reimbursement iteration, the Centers for Medicare & Medicaid Services (CMS) fulfills some longstanding policy promises while attempting to assist providers still struggling to stay afloat in a pandemic. Read on for the details.

Context: On Dec. 28, 2020, CMS published its calendar year (CY) 2021 policy and reimbursement opus, the Medicare Physician Fee Schedule (MPFS) final rule in the Federal Register. The MPFS CY 2021 offers updates on the COVID-19-inspired telehealth expansion to E/M service policy clarifications — and everything in between.

Take a Look at Finalized E/M Changes

CMS settled its long-awaited office/outpatient E/M documentation guidelines as well as payment rate increases for these codes. The feds made these changes to address providers’ burdens, streamline services, and boost pay for face-to-face E/M office visits.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” maintained CMS Administrator Seema Verma in a release. “In the past, the system has rewarded interventions and procedures over time spent with patients — time taken preventing disease and managing chronic illnesses.”

Breakdown: In 2021, you’ll use either medical decision-making (MDM) or time to choose a level of service when selecting E/M office visit codes. That means, for code selection purposes, you can ignore the history and exam elements that have long defined E/M codes. “The clinically outdated system for number of body systems/areas reviewed and examined under history and exam will no longer apply, and the history and exam components will only be performed when, and to the extent, reasonable and necessary, and clinically appropriate,” CMS explains in the rule. “We continue to believe these policies will further our ongoing effort to reduce administrative burden, improve payment accuracy, and update the O/O [office/outpatient] E/M visit code set to better reflect the current practice of medicine.”

Conversion factor: In coordination with the E/M revamp — and to the chagrin of many — CMS decided to follow through on its proposal to chop the conversion factor by a staggering 10.6 percent. However, in a last-minute stimulus package on Dec. 21, 2020, Congress circumvented this change with a turnaround policy that includes a one-time 3.75 percent boost for MPFS payments (see story, p. 4).

Telehealth Remains Front and Center in 2021 Policies

COVID-19 and the expansion of Medicare telehealth services also factored heavily in many of the MPFS’ finalized and future policies. For example, the agency determined which temporary codes it would make permanent from those added to the Medicare telehealth services list during the COVID-19 PHE.

But, even before the coronavirus threw healthcare for a loop, telehealth was a Medicare priority, according to Verma. “The pandemic accentuated just how transformative it could be, and several months in, it’s clear that the healthcare system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in healthcare delivery,” she said.

Remember: CMS published two interim final rules related to telehealth in March and May that already significantly expanded the telehealth services list, including coverage for emergency care, nursing home visits, and physical therapy. Upward of 144 telehealth services were added and are covered through the end of the PHE.

“As a result, preliminary data show that between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries and enrollees have received a Medicare telemedicine service during the PHE,” a CMS fact sheet says.

Here’s a short list of the telehealth services highlights:

New services: The MPFS finalized several new services to the Medicare telehealth services list. “The new services will allow Medicare beneficiaries to have greater access to telehealth, with a particular focus on residents of rural areas, even after the COVID-19 public health emergency ends,” explains partner attorney Eric D. Fader of Rivkin Radler LLP in the Rivkin Rounds health blog.

Category 3: The final rule created “Category 3” to deal with temporary code additions to the Medicare telehealth list added during the COVID-19 PHE and “through the calendar year in which the PHE ends,” a CMS fact sheet notes.

Nursing facilities: CMS followed through on changing telehealth visit frequency limits in subsequent nursing facilities. The agency updated the policy to one visit every 14 days from its past policy of one every 30 days.

Direct supervision: Several services can now be delivered by auxiliary personnel under the direct supervision of a physician, the final rule allows. In these cases, the supervision requirements necessitate the presence of the physician in a particular location, usually in the same location as the beneficiary when the service is provided. During the PHE, CMS is temporarily modifying the direct supervision requirement to allow for the virtual presence of the supervising physician using interactive audio/video real-time communications technology.

Medical discussion G-code: After hearing from stakeholders, CMS plans to establish a “payment on an interim final basis for a new HCPCS G-code describing 11-20 minutes of medical discussion to determine the necessity of an in-person visit,” notes the fact sheet.

Telecommunications update: CMS clarified that services furnished via telecommunications when the patient and provider are in the same place — but not in the same room because of contamination worries — are not considered telehealth.

Research: The agency announced “a commissioned study of its telehealth flexibilities provided during the COVID-19 PHE,” a fact sheet says. Researchers will look at ways to make telehealth and remote monitoring more efficient across the Medicare spectrum.

Tip: The myriad of CY 2021 MPFS final rule updates to telehealth services combined with heightened claims scrutiny makes for the perfect storm — and that’s why concise documentation is critical.

“As more and more insurance companies are contracting coders for telehealth audits, it’s imperative that specialists don’t shortchange when it comes to documentation,” advises Stephanie A. Thebarge, CPC, CPMA, CPPM, CEMC, CHONC, PESC, AAPC National Advisory Board member and compliance manager at New England Cancer Specialists in Scarborough, Maine. Practices should “still document the visit as if the patient was coming to the office — no interval notes or brief documentation. It’s best to check with each payer and understand their documentation guidelines and requirements,” she adds.

Resources: Peruse the final rule at Find the CMS fact sheet on the MPFS at www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf. See the CMS fact sheet at www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1. See more on the telehealth expansion at www.cms.gov/newsroom/press-releases/trump-administration-finalizes-permanent-expansion-medicare-telehealth-services-and-improved-payment.