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The Medicare 2021 Physician Fee Schedule: The Upshot for Neurology E/M This Year

Article In Brief

The Medicare Physician Fee Schedule for 2021 raises the reimbursement for outpatient evaluation-and-management codes significantly. Coding and bill experts offer an assessment of how it will impact neurologists.

Neurologists won big—higher pay rates, reduced documentation and recognition of the complexity of their work—in the federal government's new fee schedule that went into effect January 1.

The Medicare Physician Fee Schedule for 2021 raises the reimbursement for outpatient evaluation-and-management (E/M) codes significantly. Indeed, the Centers for Medicare & Medicaid Services (CMS) forecasts that payments across the neurology specialty will increase by 6 percent this year.

“For those who are involved in cognitive work, like a lot of neurologists, this is a long overdue recognition for the work they do,” said Korwyn Williams, MD, PhD, FAAN, a pediatric epileptologist at Phoenix Children's Hospital.

The increased reimbursement for E/M codes, however, will come at the expense of neurologists whose practices rely more heavily on EEG, EMG, and other procedures than on E/M services. By law, the physician fee schedule must be budget-neutral, meaning that increased reimbursements for certain codes must be offset by decreases for others.

The AAN, the American Medical Association (AMA) and others have been trying to get Congress to intervene before clinicians see reimbursement cuts for procedures. “We are supportive of efforts to waive budget neutrality to offset cuts to reimbursement for non-E/M services provided that it would not result in a delay or in any way undermine CMS's decision to fully implement the new E/M payment structure on January 1,” the AAN said in its summary of the new fee schedule.

Also new in 2021: CMS has created an add-on code—G2211—to account for the additional complexity inherent to E/M services for patients with conditions such as those treated by neurologists, rheumatologists and endocrinologists.

Raissa Villanueva, MD, MPH, FAAN, associate chair for neurology ambulatory operations at the University of Rochester Medical Center, said the code would be appropriate for many patients diagnosed with Parkinson's disease, multiple sclerosis, and other chronic neurologic conditions.

“The continuity and the longitudinal care that we provide for these patients can now be accounted for, which we weren't always able to do before,” she said, a member of the AAN Coding and Payment Policy subcommittee.

“The Academy believes that this is a code that most neurologists will be using if they are managing a serious or complex condition, and it increases the reimbursement for that visit,” said Dr. Williams, vice chair of the subcommittee.

New Coding Structure

The most overarching element of the new fee schedule is a major overhaul of the outpatient E/M documentation and coding guidelines. A primary goal of the changes is to reduce unnecessary documentation. Excessive and unnecessary documentation of the history and physical is no longer needed for code selection, allowing clinicians to make better use of their time with patients, said Jessica R. Gautreaux, MD, assistant professor of pediatric neurology at Louisiana State University Health Sciences Center. Instead, providers only need to document “medically appropriate history and/or examination” required for patient care without worrying about how it affects billing.

“Now you can ask about the history of the present illness without having to do things like a full review of systems if that is not pertinent,” she said. “Then you can spend most of the time talking with the patient about what you are doing and why.”

The AMA estimates that the documentation changes could save physicians, on average, 2.11 minutes per visit. For a physician who sees 20 patients per day, that translates into more than 180 hours over one year.

Members of the AAN Coding and Payment Policy Subcommittee believe that, in addition to reducing administrative burden, the changes give neurologists more flexibility in their patient encounters and provide reimbursement for work that historically has not been accounted for. The new rules allow clinicians to bill based on time—including pre-visit, face-to-face, and post-visit time—or based on the level of medical decision-making (MDM), but adapting to the new coding system will take some effort, said Brian T. Cabaniss, MD, assistant professor of neurology at Emory University.

“I think the ‘total time’ approach is completely intuitive and that's going to be a great thing,” said Dr. Cabaniss, medical director of Emory's epilepsy monitoring unit and its intracranial monitoring unit. “The medical decision-making approach is going to be a little bit more challenging at first although I think it will become second nature after you get used to coding for the types of patients you see.”

Total time approach to billing. “If you're someone who bills mostly on time, this is going to be very impactful for you,” Dr. Gautreaux said.

The length of the visit is no longer limited to face-to-face time with the patient. “You'll want to keep track of the time that you reviewed test results or things before you go into the room with a patient, the amount of time that you are with a patient, and the amount of time you spend writing the note after the visit or filling prescriptions at the end of the visit,” she said. “Now you're able to bill for all of that time.”

An important caveat: Only tasks that are performed on the day of the visit can be billed. If a neurologist reviews a patient's chart the day before the visit or drafts notes a few days after, that time cannot be billed.

Neurologists who do time-based billing should learn about two new coding options for prolonged services. For Medicare patients, the G2212 add-on code can be applied to a Level 5 office visit if total time on the date of service, including pre- and post-visit, runs between 70 and 85 minutes. Another prolonged service code—99417—is available to bill private insurers; that code is appropriate for Level 5 office visits if total time on the date of service runs between 55 and 70 minutes.

Whether private payers will cover 99417 or follow CMS' rule of using G2212 only remains to be seen, Dr. Williams said. He encourages practice administrators to ask private payers which prolonged services code they intend to honor.

Medical decision-making billing. CMS made substantial changes to the guidelines used to determine the proper codes based on decision-making. Clinicians evaluate a patient encounter in three domains—number and complexity of problems addressed; amount and/or complexity of data to be reviewed and analyzed; and risk of complications and/or morbidity or mortality of patient management—to determine the appropriate code.

“Knowing the AMA Medical Decision-Making [MDM] Table is going to be important,” said Dr. Villanueva.

The MDM coding changes only apply to code families 9920x and 9921x for outpatient new and established patients, respectively, Dr. Williams said. Outpatient consult codes will still require consideration of history, exam, and the previous MDM table. This applies for both emergency department and hospitalized patients.

In many situations, choosing to bill by total time or by medical decision-making will lead to the same code. But not all. A case study presented on the AAN website compares time-based billing with MDM billing for an established-patient visit with a 12-year-old girl with seizures. In two of the scenarios, both billing approaches led to the same code; but in a scenario that included discussing surgical recommendations, treatment alternatives, risks of sudden death and referral to neurosurgery for consultation, the MDM approach resulted in a higher code than time-based billing.

Two other case studies—one for a woman with migraine, another for a man with Parkinson's disease—on the website also illustrate scenarios in which the two billing approaches lead to the same code, as well as those in which they do not.

Getting up to Speed

This is the biggest change to E/M coding in more than two decades, so it will take time for neurologists to learn the new rules and how to best apply them to their practice. Dr. Williams encourages AAN members to use the Academy's online resources—the case studies, brief recordings, and a webinar—to get started.

The subcommittee is available to answer coding questions from AAN members, Dr. Cabaniss said, and a frequently-asked-questions document will be posted on the AAN website.

Dr. Williams suggests that each practice appoint a person to become the office expert on the MDM table and a resource for everyone else. “It's not something that you're going to learn in an hour,” he said. “We all need to get good at it, but trying to get everyone to become an expert could become overwhelming.”

Many neurologists will likely use both MDM and time-based approaches to billing. Each clinician should consider their practice style and patient population to determine which is best for a given situation, Dr. Villanueva said. As they gain experience with the two options, it will become clear which approach is best for which patient.

“It may be disease-specific or it may be patient-specific,” she said. “For example, if a clinician knows that they will spend a lot of time with a certain patient because they require more face-to-face time, they can choose to bill on time, but if another patient doesn't take as much time but is medically complicated, medical decision-making might be more appropriate.”

Dr. Gautreaux encourages neurologists to keep a copy of the MDM chart at hand and check to see whether MDM or time-based billing yields the higher payment code. “I think it's looking at every encounter both ways, just in the beginning, before you start picking one or the other as a default.”

Link Up for More Information

• AAN Resource—Billing and Coding: https://aan.com/em. Accessed on December 18, 2020.
    • CY 2021 Physician Fee Schedule Final Rule: https://go.cms.gov/3nsgtMS. Accessed on December 18, 2020.