Updated on: August 1, 2018

CMS Proposed E&M Changes: Add-on Codes: Part II

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Original story posted on: July 25, 2018

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Understanding the proposed CMS “Add-on” codes and their impact on reimbursement.

In Part I in this article series, I discussed the proposed changes to the reimbursement for office/outpatient E&M services. We will now shift our focus to new reimbursement opportunities that the Centers for Medicare & Medicaid Services (CMS) is proposing to relieve high reporting providers and primary care providers for complex patient encounters.

Again, keep in mind- these changes are at this time proposed and have not been approved for implementation. At the opening of Part I, I asked you to contemplate the proposed changes and whether you agree, or think their approach is incorrect, or feel that no changes should be made at all to E&M Guidelines. I ask for your same considerations in Part II as well.

Consider the proposed services being recommended for reimbursement and your opinion on each consideration.

Proposed Add-On Codes:

The proposed E&M changes include adding two new codes and revising one. We will review the two new codes first.

  • GPC1X: This is a new code that would add-on to ONLY the established office/outpatient CPT® code. The proposed description is Visit complexity inherit to evaluation and management associated with primary medical care. This code would be used only for primary care services to capture additional resource cost beyond those involved in the base E&M service. Expectation of this code include the following:

  • This code would only be used for established patient care

CMS states that they would expect this code to be billed on every primary care established patient.

  • This code is not reimbursing for services that could be otherwise reimbursed and it is only reimbursing for face-to-face services.

  • While the code is proposed for primary care that generally impacts family practice, internal medicine, and general medicine, CMS is accepting comments regarding “other specialties” (e.g., OB/GYN or cardiology) who are acting in the role of primary care.

  • It could also be appended as an add-on service to the new prolonged services code which we will discuss later in this article.

  • GCG0X: A proposed new code to add-on to the report office/outpatient CPT Code. The proposed description for this G code is Visit complexity inherent to E&M associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/GYN, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care. These specialties were identified because while not all service include surgical intervention the encounters demonstrate increased complexity.

  • GPRO1: While a current code exists for prolonged physician services, a new G code has been created. The proposed description is: Prolonged Evaluation and Management or psychotherapy service beyond the typical service time of the primary procedure. This new code relieves the heavy burden of meeting an additional hour above the base service, and instead changes that time to a mere 30 minutes beyond the base service. What doesn’t change however, is the specific code is for direct patient contact between the provider and the patient.

Reimbursement Impact of the Add-on Codes:

I mentioned that these add-on codes were created to help offset additional resources or higher complexity care than that represented by the base-line service. Based on the proposed guidance, CMS is well expecting that if the reimbursement model is modified to a flat blended rate then the primary care add-on code and the complexity add-on code would be appended to most every E&M encounter. Therefore, we would see an increase above and beyond the financial impacts we discussed in Part I of this article.

So, let’s see now how the additional of these add-on codes affect those reimbursement rates. The chart below includes the information from Part I and in addition shows the added impact of the add-on services:

Illustration 1: This chart identifies the reimbursement impact, utilizing the following formula proposed wRVU + proposed peRVU * 2018 conversion factor of $35.99 and then adding to that reimbursement impact the add-on code for specialty complex E&M services:

CPT Code Impacted

2018 W + PE

2019 W + PE

Reimbursement Impact

Add-on for Complex E&M

99201

1.21

1.18

$1.08

$14.08

99202

2.04

3.59

$55.78

$68.78

99203

2.9

3.59

$24.83

$37.83

99204

4.43

3.59

-$30.23

-$17.23

99205

5.56

3.59

-$70.90

-$57.90

         

99211

0.6

0.66

$0.22

$13.22

99212

1.2

2.47

$45.71

$58.71

99213

1.99

2.47

$17.28

$30.28

99214

2.94

2.47

-$16.92

-$3.92

99215

3.95

2.47

-$53.27

-$40.27



Illustration 2: This chart identifies the reimbursement impact, utilizing the following formula proposed wRVU + proposed peRVU * 2018 conversion factor of $35.99 and then adding to that reimbursement impact the add-on code for primary care services office/outpatient services:

CPT Code Impacted

2018 W + PE

2019 W + PE

Reimbursement Impact

Add-on for Primary Care Service

99201

1.21

1.18

$1.08

$6.08

99202

2.04

3.59

$55.78

$60.78

99203

2.9

3.59

$24.83

$29.83

99204

4.43

3.59

-$30.23

-$25.23

99205

5.56

3.59

-$70.90

-$65.90

         

99211

0.6

0.66

$0.22

$5.22

99212

1.2

2.47

$45.71

$50.71

99213

1.99

2.47

$17.28

$22.28

99214

2.94

2.47

-$16.92

-$11.92

99215

3.95

2.47

-$53.27

-$48.27



While these add-on codes help lessen the extent of high level E&M service reimbursement cuts, nonetheless it appears that, based on the proposed RVU considerations by CMS, (pending RUC guidance) there will still be a negative impact overall.

New E&M Service:

CMS focused attention to podiatric services and the current reimbursement and work of each encounter. In hopes helping to relieve administrative burdens for these providers while enabling them to provide service to their beneficiaries, CMS is proposing two new G codes specific to podiatry encounters:

  • GPD0X: Podiatry services, medical exam, and evaluation with initiation of diagnostic and treatment program, new patient.

  • GPD1X: Podiatry services, medical exam, and evaluation with initiation of diagnostic and treatment program, established patient.

These services were modeled after the ophthalmologic service codes in proposed RVU considerations by CMS.

Illustration 3: Using the same formula of the proposed wRVU + proposed peRVU * 2018 conversion factor of $35.99 and comparing that to the 2018 wRVU + 2018 peRVU * 2018 conversion factor of $35.99, Podiatry services proposed approximate reimbursement would be:

New Podiatry Code

2019 Proposed
W + PE RVU

Approximate Proposed Reimbursement

2018 Reimbursement Based on W + PE for Level 3 Encounters

GPD0X

2.72

$97.89

$53.27

GPD1X

1.81

$65.14

$36.71


In this illustration we used a current office level of service 3 as in the proposed CMS statute they reference this is the commonly reported code for podiatry services. This analysis indicates that this proposed change for podiatry services would have a positive impact on reimbursement.

These codes would also be reported based on medical decision-making (MDM) or time spent face-to-face with the patient even when counseling/coordination does not dominate the encounter. The expected time requirements proposed for these services are as follows:

  • GPD0X for the new patient: 28 minutes with the CPT expectation of a threshold of at least 15 minutes.

  • GPD1X for the established patient: 22 minutes with the CPT expectation of a threshold of at least 12 minutes.

Modification to Teaching Physician Attestation:

Again, in an effort to elevate some of the documentation burden for providers, CMS has also proposed documentation relaxation to the teaching physician requirements. These exceptions would not apply to services recognized as:

  • Hospital outpatient

  • Ambulatory settings

  • Renal dialysis services

  • Psychiatric services

The proposed change would modify the attestation requirements to indicate that the teaching physician was present, and information may be documented by the physician, resident, or the nurse. There would be no requirement regarding participation in the review and direction of the service, but rather the extent of review and direction that was provided as part of the encounter.

Wrap Up and Final Thoughts

As mentioned in Part I, I tried to provide the lay of the land with the proposed changes and not include any biased opinion or interpretation, but now that I am done giving this overview—and I will weigh in.

These changes seem as though they are an olive branch from CMS providing an out for extensive documentation standards, and an extension of a simplified office-based reimbursement model. But is it really? Or, is it putting all physician/non-physician practitioner (NPP)-based care on a unilateral platform, devaluing the complexity that many patient encounters require?

CMS changed the Claims Processing Manual back in 2004 to direct providers that volume of documentation alone was not the defining factor in their E&M selection, but rather the focus should be on the medical necessity of the encounter.

Have you ever thought about why CMS did that? Many think it that change was brought on by electronic medical record (EMR), but in 2004 EMRs were not dominating healthcare documentation.

Personally, I think it’s because even back when a provider dictated or completed a check yes/no handwritten template that there was too large of an opportunity to “game the system” by just generating documentation bullets. So, CMS tried to change the focus to how complex was your patient to treat and that would be the primary influence for how your claims should be paid. It makes sense.

Treating a patient with coronary disease, diabetes, and dementia is more complex, consumes more time, and carries a higher risk than a straightforward presentation of strep throat in a patient with no comorbidities. Why should the pay rate be the same?

I would like to ask you to consider this in forming your opinion regarding the proposed changes. Set aside the documentation relaxation requirements. We have dealt with those issues for nearly 30 years now? We have EMRs in most every practice that cost a mint, by the way to help meet expected documentation requirements.

I personally think your opinion and focus should be on the proposed fee schedule adjustment. In a country with out of control disease and obesity is this really the right model for physician/NPP’s to receive the same reimbursement for each patient regardless of complexity, care, risk, or compromise?

Your opinion and comments matter! Submit both to CMS for consideration!

  1. Submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”

  1. Mail written comments to:

CMS-1676-P 2
Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
P.O. Box 8016
Baltimore, MD 21244-8013.

Allow sufficient time for mailed comments to be received before the close of the comment period.

  1. By express or overnight mail. You may send written comments to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850.

  1. Deliver (by hand or courier) written comments before the close of the comment period to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW., Washington, DC 20201

Comment on this article

Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

This email address is being protected from spambots. You need JavaScript enabled to view it.

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