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Practice Matters

What the 2019 Proposed Rule by Medicare Will Mean for Your Coding — and Neurology Practice

Avitzur, Orly, MD, MBA, FAAN

doi: 10.1097/01.NT.0000547377.24734.6d
Practice Matters
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ARTICLE IN BRIEF

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In a Q&A with Neurology Today, Bruce H. Cohen, MD, FAAN, chair of the AAN Coding Subcommittee, discusses the effect of E/M changes on coding.

The CMS proposal to flatten evaluation and management (E/M) coding could have a pervasive impact on neurology practice in every setting. In an interview with Neurology Today, Bruce H. Cohen, MD, FAAN, chair of the AAN Coding Subcommittee, shed light on the effect of these changes on coding. His excerpted remarks appear here.

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THE CMS HAS RELEASED A PROPOSAL TO FLATTEN E/M CODE REIMBURSEMENT FOR LEVELS 2 TO 5 TO ONE PAYMENT. HOW DOES THAT DIFFER FROM THE CURRENT CODING STRUCTURE?

Neurologists care for a variety of conditions: some simple and some complex. Some require brief histories and physicals, others, lengthy interviews and comprehensive examinations, and a large degree of medical decision making — which could include a broad differential diagnosis, an extensive evaluation and a lengthy treatment plan. Complicating this is the fact that elderly neurologic patients and their caregivers (typically spouses) are often not well and the office visit may be extended by the need to address their cognitive and/or communication issues.

E/M codes allow the clinician to choose one of two systems that lead to the proper choice of a Current Procedural Terminology (CPT) code: bullets or time. Because CPT is a “value-based” system, achieving and documenting the proper bullets, irrelevant of time, allows a CPT code to be selected. Although a typical time has been assigned to each level of service, if the required bullets are selected, the time of the visit is not relevant.

For example, the (highest level) established visit code, 99215, is assigned a visit duration of 40 minutes. If the clinician chooses to spend 40 minutes with the patient, and the majority of time is spent on counselling and coordination of care, the requirement for this code has been established. Alternatively, if the clinician performs a comprehensive physical and comprehensive examination instead, even if this requires only 13 minutes (there is no lower time limit), the 99215 code can be submitted. One could argue that spending so little time does not justify such a high level of coding, but it is accepted and expected that as long as the chief complaint and nature of the illness warrant the need to perform a comprehensive history and examination, the code choice is justified. New patient codes, of course, require either time, in the context of counseling and coordination of care, or all three components of the office visit: history, examination, and the medical decision to be considered in choosing the correct level of service.

For those neurologists with practices that allow them to submit codes based on the bullet-based system and who tend to be very efficient with their time, and for practices that tend to mainly bill level 3 and 4 (99203/4 and 99213/4) ambulatory codes, the proposed system of collapsing codes may in fact offer a financial advantage, or at least allow them to break even. For those practices that utilize time-based billing, or those with complex patients and that choose level 4 and 5 codes primarily, the financial loss projected with the proposed Medicare fee schedule changes is substantial.

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CMS SUGGESTS PAYING PHYSICIANS $134 FOR EACH NEW E/M PATIENT VISIT AND $92 FOR EACH ESTABLISHED PATIENT VISIT, REGARDLESS OF COMPLEITY OR LENGTH OF VISIT. THEY HAVE ALSO SUGGESTED ADD-ON CODES THAT MAY GIVE NEUROLOGISTS A “BUMP.” CAN YOU PUT THIS INTO A DOLLARS AND CENTS PERSPECTIVE?

There are two add-on codes being considered: 1) GCG0X for use for E/M office visits by specialists in several specialties including neurology, and 2) GPRO1 prolonged services code for care 30 minutes beyond the typical time for the base code.

These codes are up in the air, and CMS may eliminate them altogether. The original plan was to allow those clinicians who both performed mainly E/M services and cared for complex patients, which included neurologists, to receive an extra, approximately $13.70, for each visit. However, the interpretation of that code was extended to state that any clinician who provided care for patients with these illnesses will be able to use the code. This might mean that if a family physician inquired/documented discussion about gabapentin side effects as part of the office visit for rhinorrhea, and then listed diabetic polyneuropathy as an ICD-10-CM diagnostic code, the new add-on code could be utilized.

Depending on the add-on specialty code, which may or may not be allowed in the final plan, the payment would equate to a level “3.5” visit, meaning about halfway between a level 3 visit and a level 4 visit. It is not clear if the 30 minute add-on code can be used at just past the half-way point (16 minutes) or if it will require the full 30 minutes of additional time before it can be used.

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IN THE PUBLIC SUMMARY OF THE MAY CPT EDITORIAL PANEL MEETING, A REVISED FAMILY OF LONG-TERM EEG MONITORING CODES WAS ACCEPTED BY THE PANEL AND WILL NOW BE REVIEWED BY THE RVS UPDATE COMMITTEE (RUC). BASED ON PREVIOUS PATTERNS, THE CODES MAY BE DEVALUED AND THE REPERCUSSIONS WILL BE TREMENDOUS TO NEUROLOGY DEPARTMENTS. WHILE RUC PROCEEDINGS ARE CONFIDENTIAL, CAN YOU TELL US HOW THEY WORK?

According to the American Medical Association CPT/ RUC process, the long-term EEG codes will now be reviewed by the RUC, which will in turn submit relative value unit (RVU) and practice expense recommendations to CMS. CMS will publish values as part of the Medicare proposed rule, scheduled for release on or about July 1, 2019. The AAN has the opportunity to submit official comments to CMS as part of the rulemaking process, which will allow the AAN to provide feedback to CMS on any new codes. The Medicare final rule will be released on or about November 1, 2019 and contain the final values of codes scheduled for implementation on January 1, 2020. This will allow only two months for neurologists and their operation managers to develop a plan that could require a change in operations just to meet any new standards required to provide services for this code.

By law, the new CPT code structure is under AMA embargo, and cannot be released until CPT publishes them around August of each year, and the RVU valuations are known only about two months before they are implemented. Therefore, there is little time to “prepare,” and the entire country prepares during those same two months. For a neurologist who owns their practice, their equipment, and the staff and buildings that provide this service, all discussions about operations will obviously be internal. However, in many academic and hospital-based centers, the equipment, nursing and technical staff, as well as the facility itself is owned and managed by the medical center, and income derived from the professional and technical fees are likely divided by agreements that may be decades old. Any change in operations or income allocation would require a nimble administrative structure to develop institutional plans during that two-month period.

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HOW HAS THE CMS RESPONDED TO PREVIOUS RUC RECOMMENDATIONS?

CMS has not accepted some of the RUC valuations, and this has impacted neurology practices. The electromyography (EMG) and nerve conduction code experience provides the best example of a situation in which the CMS valuation was markedly reduced form those deemed fair by the RUC. At that time, CMS did not include values of new CPT codes in their proposed rule (in July); rather they were only included in the final rule (in November) limiting the ability of stakeholders to provide feedback on new codes. Since that time, the timeline has shifted allowing medical specialty societies the opportunity to provide comments to CMS following the proposed rule. Neurology is not the only subspecialty affected. On the positive side, CMS has requested and approved the non-face-to-face E/M codes such as the transition of care and chronic care management codes. Both of these code sets are appropriate for many neurology practices.

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HAVE THE CPT AND RUC PROCESSES HELPED NEUROLOGISTS OR ANY PHYSICIAN GROUP?

In my seven years working as the CPT assistant advisor and CPT advisor, I have not seen the CPT and RUC process lead to any “huge wins” for any physician group or medical industry. I think the processes have weeded out some inappropriate billing practices, such as duplicate consecutive billing for therapy services. The revision of the EMG codes was one example where neurologists took a huge economic hit, but reduced the use of these codes by clinicians without the rigorous training required in neurology and physical medicine and rehabilitation programs. Although “we” suffered, our patients that require these services are now getting them mainly by those clinicians that are best trained to perform them. The medical societies that include cardiologists and gastroenterologists have not benefited financially by their high-earning codes having gone through the process. There are many more examples that suggest that no group in American medicine is feeling “joy” about their economic situation in the face of the regulatory environment.

The AAN CPT and RUC advisors and staff must take oaths that their work is conducted in fairness and not to the inappropriate financial advantage of their organization, but to the benefit of American medicine and the persons in need of medical care. Having said this, we strongly advocate for the need to provide nothing short of first rate medical care and the practice necessities that are needed to do this (on the CPT side) and the costs required to perform this (on the RUC side). It would be illegal for the AAN to lobby CMS in the fashion that the AAN BrainPAC is able to lobby Congress. However, the AAN does reply with vigorous letters in response to posted rule proposals.

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SOME EXPERTS THINK THE CMS PROPOSAL IS A WAY TO GET PRACTICES AND HEALTH SYSTEMS TO MOVE TO VALUE-BASED CARE. AS DIRECTOR OF THE NEURODEVELOPMENTAL SCIENCE CENTER AT AKRON'S CHILDREN'S HOSPITAL, WHAT IS YOUR INSTITUTION DOING TO PREPARE?

We are going all in for value-based care. We have hired experts to help develop the strategy and models and are hiring PhD researchers to assist us with the proper academic projects to help us and others decide how to proceed in this brave new world. Several universities in our area have interesting technologies that map disease and health care utilization by very tiny geographical voxels. We currently do participate in an alternative payment model with tens of thousands of patients' lives covered. We are also investing heavily in telemedicine technology to allow us to best care for patients in this new world of medicine.

© 2018 American Academy of Neurology