Thread by @BillFoxMD

OK. I am just now sitting down to look at the proposed #PFS CY 2020, and judging by the summary statement, it looks like @CMSGov accepted all of our RUC/CPT proposals. @BetsyNicoletti @rshawnm @signaturedoc @jakequintonMD @SEricksonACP @yejnes @RobertBlaser1

So this will be an exciting read and a huge boost for primary care and cognitive specialists which will raise reimbursement and at the same time decrease documentation burden for E/M codes.

So first, @CMSGov is proposing to add office based treatment for opioid use disorder to the Medicare Telehealth list (p. 110). This will certainly reduce barriers to treating substance abuse disorders

By the way, the public did not nominate any potential additions to the Medicare telehealth list for 2020. If you think there are good codes that should be covered under telehealth, you can directly nominate those to Medicare!

Supervision of PAs is addressed on p 207: scope of PA practice now varies by state, and therefore Medicare requirement for general supervision of PA services is increasingly out of step with local practices.

Therefore, Medicare is revising physician supervision for PA services as being met when the PA furnishes their services in accordance with state law and scope of practice.m (p. 209)

Documentation relief: CMS proposes to allow the physician, PA, or the advance practice nurse to review and verify, rather than re-document, information included in the record by physicians, residents, nurses, students, or other members of the medical team (p 214)

Apparently, there was some confusion as to the definition of a student that this provision clarifies. Also clarifies that non-physician teachers do not have to re-document either

CMS believes that transitional care management codes are underutilized (p 217). Latest utilization is 1.3 million claims in 2018. TCM is associated with reduced readmission rates, lower mortality, and lower healthcare costs. Many more patients could benefit.

As such, CMS is accepting the RUC recommendations to increase 99495 to 2.36 wRV (from 2.11) and 99496 to 3.10 (from 3.05) (p 221)

For the CCM codes, Medicare states that utilization has reached approximately 75% of the level that was initially assumed when it was started but they feel it is still under utilized (p. 222)

So Medicare proposes paying for CCM for every 20 minute increment, instead of just for a single 20 minute block of time. This is something @ACPinternists has petitioned CMS to do for the last several years. These will now be G codes instead of the code 99490

Likewise, complex chronic care management codes will also be moved to G codes (p 228) and substantial care plan revision will not be required.

The idea is that these changes will increase utilization of CCM codes.

CCM billing requires that a patient have two or more chronic conditions. But CMS identifies a gap for patients who need this service but only have one high-risk chronic condition. Ladies and gents, introducing principal care management (PCM) services! (P 231)

PCM services might be furnished by specialists for single high-risk illnesses, but there are no restrictions on who could bill for it. These will also be G codes.

GPPP1 = 30 min and 1.28 wRV. GPPP2 = ? Each additional 30 minutes and 0.61 wRV. These services would require verbal consent and a care plan, the same as CCM

On p 242, @CMSGov recognizes that it is burdensome to obtain consent at the outset a brief electronic check in services. This is something @ACPinternists has been concerned about. CMS now seeking comments on whether a single advance beneficiary consent could be obtained -YES!

CMS recognizes the problem where if you get a colonoscopy and a polyp is found, Medicare won’t cover the colonoscopy as a screening procedure at 100%. However, it states that because of statute it can’t do anything about this. Big bummer! (p 247)

OK, now to the specific code valuations section. Medicare continues to be concerned about decreases in time not accompanied by appropriate decreases in valuations. This is a recurring theme over the years (p 279).

now for the good stuff! E/M starts on page 491 and gets its own section.

The background here is that there was a significant backlash to the proposed blended payment rate and @AmerMedicalAssn established the joint AMA RUC/CPT Work group to come up with an alternative.

Level of billing will be based on either time or medical decision-making only. This in another itself is a huge burden reduction. No longer will physicians need to account for nonsensical bullet points in their history and physical exams (p 502)

The documentation of the history and physical is only what is considered medically appropriate. Thank you, thank you, thank you @SeemaCMS

When time is chosen to determine the level of service, total time spent on all activities for that patient on the day of service are counted. This is an end to the “greater than 50% of time spent on counseling and coordination of care“ requirement

This is a vital acknowledgment- that all the work for an E/M visit is considered equally valid & important, whether it be reviewing the notes before you enter the room, or developing a differential diagnosis after you leave the room.

This was a brilliant recognition by the CPT workgroup that developed the criteria IMO (I was not on that committee) including Barbara Levy, Peter Hollman, Doug Leahy, Scott Manaker, Margie Andreas, and others

99201 Will be eliminated. There will also be an add-on code for each additional 15 minutes beyond the highest level of service when time is used to select a visit level.(p 503)

The add-on code will kick in at 55 minutes for a level 99215, and 75 minutes for a level 99205 and can be reported multiple times for each additional 15 minutes.

The typical prolonged services code 99358 and 99359 will likely now need to be re-valued (p 504)

All of these changes in documentation guidelines and values will not take effect until 2021. CMS states it will give clinicians time to make necessary process and system adjustments (p 505). I wish it could be 2020!

On page 505, CMS echoes the concerns of MedPAC that the E/M code set has become passively devalued, which provides further rationale for accepting the RUC recommendations to increase the value of E/M codes.

The strength of the new values is further based on the fact that our survey included over 50 specialty societies and anywhere from 700 to 1100 responses. This is some of the most robust data presented before the RUC (p 508)

Unfortunately, @CMSGov did not agree with our request to include a desktop computer as part of our practice expense costs (p 508) instead, stating this is better characterized as an indirect cost. @ACPinternists respectfully disagrees.

By the way, when medical decision-making is used to determine the level of service, there are three elements: Number and complexity of problems, amount/complexity of data to be reviewed, and risk/potential complications of management

It is too much to go into the specifics via Twitter, but two of three of these elements must be satisfied to bill at a specific level. The elements overall have been clarified and are easier to follow compared to the prior Marshfield rules.

So the new wRV values old -> new (I can’t seem to find the total RVU so if somebody has that, let me know!):
99202 0.93 -> 0.93
99203 1.42 -> 1.6
99204 2.43 -> 2.6
99205. 3.17 -> 3.5

And for established
99211 0.18 -> 0.18
99212 0.48 -> 0.7
99213 0.97 -> 1.3
99214 1.5 -> 1.92
99215 2.11 -> 2.8

This represents wRV increases of between 10 and 30%

P 513: to me, this is one of the biggest surprises: I thought for sure when CMS eliminated the blended payment model, it would also eliminate the primary care and specialist add on modifiers.

Per CMS: “ we believe that there is still a need for add on coding because the revised E/M codes set does not recognize that there are additional resource costs in furnishing primary care and certain specialty visits.”

These add on codes, which are G codes, will now be the same for primary care and certain specialties and will be valued at 0.33 wRVU (p 514). This code can be billed with every level of the E/M visit.

The 15 minute prolonged service code will be valued at 0.61 wRVU

Now regarding the issue of the global periods (p 520) CMS reminds us that the RAND data shows only 4% of procedures with 10 day global period had any postop visits reported, and only 39% of expected postop visits in 90 day globals were reported

However, once again, CMS has decided not to take any action on changing or revaluing the global periods

All in all, this is one of the most bold and amazing #PFS schedules to be released and recognizes years of under valuation of cognitive services. A big thank you to @CMSGov and @SeemaCMS

Cognitive specialties will see an income bump up between 4% and 16%. Those who will not make out quite as well include anesthesia, neurosurgery, ophthalmology, and thoracic surgery.

Nephrology unfortunately is predicted to take a slight hit as his infectious diseases, for reasons that do not at all seem clear to me.

This was a multi year effort to get this proposal across the finish line including a lot of work of multiple people and organizations including @ACPinternists @AANMember @AmerGeriatrics @ACCinTouch @aafp @AmerAcadPeds @AAHPM @APMA and others.

It demonstrates what the house of medicine can do when it works together. And to its credit, the RUC had the courage under the leadership of Peter Smith MD to achieve this remarkably heavy lift. It wasn’t easy but they got it done.

Ok. Signing off. Thank you Twitter!