Thread by @BillFoxMD

What else for a @CMSGov coding and payment geek to do on a Friday night except dig into the 2066 page #PFS proposed rule! @SEricksonACP @BobDohertyACP @RobertBlaser1 @signaturedoc @BetsyNicoletti

Have to start with a shout out to @RobertBlaser1 coding guru from @RPANephrology who has his own thread on the #PFS. It was great to connect with him in Chicago last month

I have to start with a side rant on the conversion factor though. The CF will go down $1.53 to $33.08–a 4.4% decrease! This reflects a statutory freeze on automatic increases to the PFS coupled with the expiration of the some $3b that was pumped into the fee schedule last year

This decrease in the CF doesn’t include addnl cuts slated to into effect next year including a 4% paygo cut and a 2% sequester cut. So the true CF could likely go down by as much as 10%.

Bear in mind that for #MCare Part A hospital svcs, Congress typically approves a pay increases on an annual basis. But not for Part B physician svcs. In fact @medicarepayment recommended no pay increase for physicians this year as “beneficiaries have adequate access to care”

This has led economists at @AmerMedicalAssn to find earlier this year that when adjusted for inflation, physician payments have actually decreased by 20% over the past 20 years. This is clearly not sustainable.

So, before the end of the year, physicians, who have been doing the lions share of the work helping America thru this pandemic (at enormous physical and emotional risk to themselves) will once again have to go to Congress, hat in hand, and ask for their pay not to be cut

It is embarrassing that Congress has not dealt with this yet @SenFinance @WaysMeansCmte . The effects on our healthcare infrastructure are becoming clear.

Take my home town of #Charlottesville, a community where people retire because of the historically superb access to healthcare. Now, waits for ENT are 2-3 months, pulmonary 4 months, Neurology 4-8 months, and Rheum: patients no longer being accepted except on emergency basis

But now some good news, telehealth flexibilities related to geographic and originating site restrictions will remain in effect for 151 days beyond PHE, and temporary additions to the telehealth services list will remain thru CY 2023

This is vital for us physicians on the front lines to deliver adequate care…and so helpful for our patients who can’t always get into the office. It also helps further #healthequity

Telephone E/M will NOT remain on the category III telehealth list at the end of the PHI, unfortunately, but will be allowed for mental health evaluations/services (P 89)

It took a long time to make it to page 267, where inpatient E/M codes have been reworked by the #RUC to parallel the changes of the outpatient E/M codes that went into effect 1/1/21

For inpatient E/M, you will now be able to choose a level of service based on time or MDM. The administrative burden relief of such a rule change cannot be overstated.

I think a big shout out here has to go to the @ACPinternists & @ACCinTouch teams and their partner specialty societies for leading the way on these important changes @SEricksonACP

While there will be a slight decrease in wRVUs for the initial inpatient codes, the increase in wRVUs for subsequent day codes should more than offset that. And don’t forget the administrative simplification!

In addition, to allow for further administrative simplification, the observation codes will be sunset and the same CPT codes will now be used for patients on either observation status or inpatient status. The old system was clearly more cumbersome

P 267 has the new code valuations (compared to previous value)
99221: 1.92 —> 1.63
99222: 2.61 —> 2.60
99223: 3.86 —> 3.50
99231: 0.76. —> 1.00
99232: 1.39 —> 1.59
99233: 2.00 —> 2.40
99234: 2.56 —> 2.00
99235: 3.24 —> 3.24
99236: 4.20 —> 4.30

As CMS says on P 298, “History and physical exam will only be considered when and to the extent that they are medically appropriate and will no longer impact the visit level”
It’s important that CMS end the “bullet point” approach to documentation, which they did with this rule

By the way, have you ever wondered what the difference is between a domiciliary visit and a home visit? Well, now you don’t have to worry. These codes have also been consolidated into a single code set, which is also billed based on time or MDM (codes 99341-99350) P 339

Interestingly, CMS did not accept the RUC/CPT code for prolonged inpatient service 993X0, in much the same way it did not accept the outpatient prolonged service codes two years ago. CMS feels these codes don’t truly reflect prolonged times according to the code descriptors P 315

Instead, CMS has created code GXXX1 for prolonged service of each 15 minute addnl increment as follows:
99223: triggers at 105 minutes
99233: triggers at 80 minutes
99236: triggers at 125 minutes

And here I echo @RobertBlaser1 regarding consult codes (P 347). Per CMS: “We did not review the RUC recommendations for the eight revised consult codes. We note that CMS stopped paying for the consultation codes beginning in CY 2010.” Harsh!

P 348 speaks to split/shared billing. CMS was going to finalize that “more than half the total time” spent on the visit would constitute the substantive portion of the visit for the purposes of who could bill. This has significant implications of whether the MD or APP would bill

Many specialty societies pushed back. CMS listened and will delay this rule until 1/2024. Until then, they will allow the “substantive portion” of the visit to be the substantive portion of MDM, history, or exam.

However CMS also indicated it had every intent to use time to determine substantive portion of the visit and plans to implement this rule in 1/2024. But it left the door open to check snider other feedback

This issue is important because CMS’ proposed rule doesn’t seem to recognize the value of the physician-led team. IMO CMS needs to revamp the whole policy to allow for something like incident-to billing that we see in the outpatient setting. This will take a lot of advocacy.

So, this is somewhat of a win in that this proposed rule is being put on hold. But CMS language makes me concerned that this is just a one year delay

One last tweet for the evening. Typically, CMS accepts around 90% of RUC recommendations. Based on my quick read, it looks like CMS has only accepted about 65% of RUC valuations this year. That may be a new low and may speak to greater independent analysis at CMS.
G’Night!