May 28, 2020 02:03 pm David Mitchell – Significant changes are coming to office/outpatient evaluation and management visit coding and payment, and the AAFP is rolling out resources to help members take full advantage of them. Although the updates aren't scheduled to take effect until Jan. 1, the Academy is urging members to act now.
"There might be some procrastination by physicians who remember the rollout of ICD-10 being held for a year and then another year," said Carol Self, the Academy's coding and compliance strategist. "This isn't likely to be held up. We're forging ahead."
In response to advocacy from the AAFP and other organizations, the AMA revised the methodology to document and select CPT levels for office visit E/M services in 2019. CMS will use the updated methodology, meaning its 1995 and 1997 guidelines will no longer apply, and the Academy is advocating for uniform adoption of the changes across all payers.
The changes are intended to increase the amount of time physicians can spend with patients and reduce administrative burden. Physicians will have the option to select the level of code using either total time or level of medical decision-making. Further, the definition of total time will expand to include all time spent in the care of the patient, both face-to-face and nonface-to-face time on the date of the encounter. In addition, criteria for medical decision-making levels will also be updated. The patient history and physical exam elements will be eliminated as components of E/M code level selection.
"It's going to change everything, including EHRs and clinical practice," Self said. "For example, when a patient calls for an appointment to follow up after an ER visit, reviewing the ER notes can count toward the physician's total time. The appointment scheduler needs to be responsible for getting that data so the physician can review it."
Likewise, tasks such as reviewing X-rays or labs and consulting with other physicians also can count toward total time, said Self, who also noted that the Academy has been in conversations with vendors of EHR and practice management systems regarding how to best capture time and medical decision-making information.
The Academy has launched three new resources (and more are on the way):
Self said it's critical for practices to communicate with their EHR vendors -- and if practices use separate platforms for their EHR and billing systems, they should talk to both vendors. Key questions to ask include whether the vendors plan to test their upgrades, whether they anticipate down time or holding periods for claims, what process they intend to use for their upgrades, and whether there will be a cost to practices.
Self said there will be physician time and staff time involved in preparing for the transition, so practices should begin getting ready now to avoid a last-minute rush in December or January. The Academy's resources offer a path to spread those time demands over the next several months.
Although the transition will take some effort, primary care physicians should see a payoff on that investment. In addition to the changes in coding, the 2021 Medicare physician fee schedule is slated to include a 12% increase for primary care.
"Commercial payers usually base their payments on a percentage of Medicare," Self said, "so things will change across the board."
Medicare has also created a new Healthcare Common Procedure Coding System code, or G code, for primary care. The new code is intended to represent the visit complexity inherent to E/M services that serve as the continuing focal point for all needed health care services and/or medical care services that are part of ongoing care related to a patient's single, serious or complex chronic condition. The add-on code will be added to E/M services. Medicare anticipates that all E/M services provided by a primary care physician will qualify for the add-on code.
Information regarding the value of the new code is likely to be included when CMS publishes its proposed 2021 Medicare physician fee schedule this summer.
Not only will physicians, payers and vendors have adjustments to make, Self suggested that practices should communicate with patients regarding the changes.
"If I'm a patient with diabetes who sees my primary care physician four times a year and it always costs $80 a visit -- and the cost hasn't changed for a long time -- and now it suddenly costs $95, that's a significant change," Self said.