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3 proposed changes to Medicare Physician Fee Schedule important for pediatrics :

September 27, 2019

The Centers for Medicare & Medicaid Services (CMS) recently published the 2020 Medicare Physician Fee Schedule (MPFS) Proposed Rule. While many issues are included in the 1,700-page rule, three are of particular importance to pediatrics: e-visits, emergency department (ED) visits and office visits.

E-visits (9X0X1-9X0X3)

The Academy championed the development and valuation of new e-visit CPT codes to replace code 99444. Since CMS never published values for code 99444, the AAP agreed to rewrite the code with more clarity and introduce time increments.

The Academy proposed replacing 99444 with three new codes (see chart). CMS proposes to accept the relative value units (RVUs) recommended by the Relative Value Scale Update Committee (RUC) for the new e-visit codes beginning Jan. 1

Emergency department visits (99281-99285)

After receiving comments suggesting that the ED evaluation and management (E/M) codes in the 2018 MPFS proposed rule are potentially undervalued, CMS referred the codes to the RUC.

The AAP and the American College of Emergency Physicians were the only specialty societies that indicated an interest in surveying the codes for the RUC.

Because AAP recommendations represented an increase in work RVUs across the code family, the AAP first had to present the RUC with compelling evidence, which focused on a change in physician work and a rank order anomaly between the ED E/M codes and new patient office visit codes revalued in 2010. Once the RUC accepted the evidence, the AAP was allowed to present valuation recommendations.

CMS proposes to accept the following RUC-recommended ED E/M valuation for 2020:

Office visit codes (99202-99205, 99211-99215 and 99XXX)

Note: The office visit codes are discussed in the 2020 proposed rule, but implementation will occur in 2021. This allows for an expanded implementation timeline.

In July 2018, CMS released the 2019 MPFS Proposed Rule, which outlined several expansive revisions to payment and coding for office or outpatient E/M services. In response, organized medicine formed a CPT-RUC Workgroup on E/M to determine the best coding structure to foster burden reduction, while ensuring appropriate valuation. Margie C. Andreae, M.D., FAAP, was the AAP representative on this workgroup.

The workgroup’s proposals were approved by the February 2019 CPT Editorial Panel and surveyed for valuation during the April 2019 RUC meeting. The AAP participated in the RUC survey as part of a 50 specialty society coalition.

CMS proposes to accept the workgroup’s revised office visit codes and their RUC-recommended values for 2021. This means that CMS’ initial (July 2018) proposal to “blend” payment for office visit codes no longer is under consideration.

CMS proposes to adopt the following policies for office visits effective Jan. 1, 2021:

  • Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective Jan. 1, 2021, and resurveyed by the RUC. This includes deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215.
  • Elimination of the use of history and/or physical exam to determine code levels.
  • Choice of time* or medical decision-making to decide the code level of office/outpatient E/M visit.

*For coding purposes, time for these services includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter but does not include time in activities normally performed by clinical staff.

Physician/other qualified health care professional time includes the following activities, when performed:

  • Preparing to see the patient (e.g., review of tests).
  • Obtaining and/or reviewing separately obtained history.
  • Performing a medically appropriate examination and/or evaluation.
  • Counseling and educating the patient/family/caregiver.
  • Ordering medications, tests or procedures.
  • Referring and communicating with other health care professionals (not separately reported).
  • Documenting clinical information in the electronic or other health record.
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
  • Care coordination (not separately reported).

CMS proposes to accept the following RUC-recommended office visit codes and valuation recommendations for 2021:

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