By Stacey Stuhrenberg, Kraft Healthcare Consulting
The 2021 Medicare Physician Fee Schedule Final Rule has been published, and Congress has signed it into law. Are you prepared for a potential change in revenue, a compliance audit, or both?
After the Centers for Medicare and Medicaid Services (CMS) released the updates on Dec. 1, 2020, Congress passed the Consolidated Appropriations Act (CAA) on Dec. 21, 2020, effectively raising the conversion factor from $32.41 to $34.89, which resulted in a 3.75% increase in fee schedule payments to providers.
The CAA called for a three-year suspension of payments for HCPCS Code G2211, an add-on code for visit complexity inherent to evaluation and management visits. According to the American Medical Association (AMA), this code accounted for approximately $3 billion of Medicare Physician Fee Schedule spending. By delaying the implementation of this code, the CMS was able to reduce the budget neutrality adjustment. It should be noted that G2211 is still reflected in CMS OPPS Addendum B as an active code with status code indicator “N,” which indicates that “Items and Services Packaged into APC Rates.”
CMS made major policy/guideline changes to evaluation and management CPT codes 99202- 99215, as well as increased the wRVU for these codes. According to CMS, these codes represent 40% of all reported CPT codes as well as 20% of revenue.
One of the potentially biggest changes for physicians to remember is CPT code 99214, which was used more than 105 million times in 2019 with billings totaling more than $10 million. The 2021 allowable rate increased to $122.31, up from $103.09 in 2020, and that difference of $19.22 per patient can add up to thousands of dollars in revenue every year. It’s a significant loss or gain resulting from a single coding practice.
To offset the increased payments in the finalized evaluation and management changes, CMS made reductions across the board to remain budget neutral. The increase/decrease in payments are expected to range from 16% to minus-10% depending on specialty. Radiologist, chiropractors, and cardiac surgeons are expected to see a negative impact, while endocrinology and family practices are expected to see a positive impact.
Keeping the above in mind, the following imperatives apply:
- Policies and procedures: Review to ensure they are consistent with new guidelines
- Baseline audit: Perform a baseline coding, documentation, and compliance audit for each provider. This is especially important for providers who see patients both in the office and in a facility setting. However, all providers should keep in mind whether they are selecting the code or EMR is auto selecting the code, an audit should be performed to ensure accuracy for both compliance and revenue purposes.
- Patient case mix: Understand your patient case mix. Practices that have a heavy workers compensation case mix won’t be as affected.
- Utilization: Review CPT code utilization for each provider. Compare and analyze the first quarter of 2021 to your fourth quarter of 2020. Are they consistent? Have new patterns emerged?
Stacey Stuhrenberg (CMPE, CPC, CPB, CPMA, CPPM, CEMC, CHCO) is a senior consultant for coding and compliance at Kraft Healthcare Consulting in Nashville. She notes Kraft Healthcare Consulting has developed programs and techniques that will help ensure compliance while also making sure clients are not leaving money on the table. To reach out for guidance, call Stacey at (615) 346-2455 or email firstname.lastname@example.org.