Pediatric Coding Alert

Plus: You will see an extra $40.39 for every month of chronic care management.

When the Centers for Medicare and Medicaid Services (CMS) announced on Halloween that it had published the 2015 Physician Fee Schedule Final rule, many practices were a bit spooked to review it—but fortunately, the finalized version of the document doesn’t differ too wildly from the proposal that the agency published earlier this year. 

The 1,185-page document is applicable to your pediatric practice because most private payers base their fees on Medicare payment amounts. Read on to find out which items in the document are most important to your practice.

Don’t Get Attached to Global Periods

Following through on suggestions that were in the proposed rule, CMS has confirmed that it will phase out global periods. In 2017, all services with 10-day global periods will be assigned zero-day globals, and by 2018, the 90-day globals will fall to zero days as well. 

Because CMS seems to believe that the government is wasting cash by paying doctors for global periods that include visits the doctors don’t actually perform, CMS will start evaluating whether a better payment model could be created to reimburse doctors for surgical services “that incentivizes care coordination and care redesign across an episode of care,” CMS says in its fact sheet.

For example: Code 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) currently has a 10-day global period, which means that if you stitch up a patient’s head wound, you must include all postsurgical services for the next ten days into the fee you get for the code. However, in 2017, you could get to bill for follow-up visits within that ten day period separately.

In addition, other procedure codes with global periods commonly provided by pediatricians include 10-day global services such as simple incision and drainage (10060), subcutaneous foreign body removal (10120), wart treatment (17110-17111), radial head subluxation, also known as “nursemaid’s elbow,” (24640). In addition, pediatricians see 90-day global periods for services such as closed clavicle fracture treatment (23500) and closed distal phalanx fracture treatment (26750). 

Telehealth Payments Could Come Your Way

Telemedicine continues to develop, especially in remote areas where access to care is an issue. CMS has added several services as payable under the telehealth benefit effective Jan. 1, including family psychotherapy (90846-90847) and prolonged services (add-on codes 99354-99355).

Keep in mind that a phone call won’t allow you to meet the telehealth requirement—you need a two-way, real-time communication system that includes both audio and video, such as a Skype session. “Telephones, facsimile machines and electronic mail systems do not meet the definition of an interactive telecommunications system,” CMS says in the Final Rule.

No Negative Conversion Factor—Yet

When it comes to the conversion factor, the fee schedule had some good news. Because the government won’t allow any cuts in the conversion factor through March 31, 2015, CMS has finalized the conversion factor of 35.8013 through that date. This differs slightly from the current conversion factor of 35.8228. “From Jan. 1 to March 31, the conversion factor will be 35.8013,” said CMS’s Kathy Bryant during a Nov. 12 CMS Open Door Forum. “The difference between those two is related to the budget neutrality adjustment that was necessary based upon changes we made in the RVUs and fee schedule of -0.06 percent,” she said. 

Starting April 1, however, you’ll be looking at a conversion factor cut of 21.2 percent (down to $28.2239) through the end of 2015 unless Congress votes to reverse the cut.

“In most prior years, Congress has taken action to avert a large reduction in Physician Fee Schedule rates before they went into effect,” CMS says in a fact sheet about the new fee schedule. Of course, whether the payment system gets an overhaul in the near future will be anyone’s guess, but with both physicians and CMS supporting a change to it, something might transpire in the coming months.

Fortunately, however, pediatricians won’t see additional cuts on top of that 21.2 percent, even though some other specialists (such as ophthalmologists) will. Pediatric pay is projected to stay at 2014 levels next year, while other primary care physicians such as family practitioners and emergency room physicians are expected to enjoy a one percent raise each.

Chronic Care Pay Will Offer Extra Reimbursement

It makes sense that primary care doctors won’t see pay cuts, since CMS appears to be following through on its promise to offer separate payment for chronic care management (CCM) services starting in 2015. CMS has confirmed a $40.39 payment rate for the CCM code (99490), which can be billed once a month for qualified patients. The CCM code will be classified as a non-face-to-face service for patients with at least two significant chronic conditions. These services will include “regular development and revision of a plan of care, communication with other treating health professionals and medication management,” CMS says.

Here’s the catch: You’ll soon need an electronic health record (EHR) system “that is in use on December 31 of the prior calendar year for the EHR Incentive Programs to bill for CCM services,” the agency says. This means that if you want to collect for CCM in 2015, you’ll need to have your certified EHR in use by Dec. 31 of this year.

To read the complete final rule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-26183.pdf.