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Value-based care stunted from delayed Stark and anti-kickback statute reform
Anti-kickback statutes (AKSs) were originally enacted in 1931 to stop Great Depression–era employers from circumventing wage provisions in federal contracts. Since its enactment, AKSs’ main focus has changed and is currently aimed at the health care industry. In addition to AKSs, Stark laws were enacted over 30 years ago to address physician self-referral of Medicare patients. Both laws comprise the government’s main tools for fighting fraud, waste, and abuse.
However, AKSs and Stark laws have not been updated to keep pace with changes in how medical practices do business and care for patients.
Over the years, additional interpretation and clarification has been issued by the Department of Health and Human Services (DHHS) and the Office of Inspector General (OIG). In DHHSs’ June 1, 2012 Advisory Opinion No. 12-06 there is guidance regarding legality of anesthesia services providers’ contract with physician-owned professional corporations or limited liability companies to provide anesthesia services. Specifically, it focused on the “company model” where owners of an ambulatory surgery center (ASC) create a separate company for anesthesia services which directly contracts with anesthesia providers and charges for the anesthesia services while the ASC charges for facility fees. Anyone with specific questions may request an advisory opinion from the OIG about the application of OIG’s fraud and abuse authorities and existing or proposed business arrangements. An OIG advisory opinion is legally binding on the requesting party and DHHS, but not on any other governmental department or agency. While advisory opinions are specific to the entity that requested it and specifically states, “This opinion may not be relied on by any persons other than [name redacted], the requestor of this opinion....” It captured the attention of the medical community. The AGA has argued that this opinion should not be interpreted to mean that all company model frameworks necessarily violate the AKSs and the OIG’s Advisor Opinions FAQ states no person or entity can rely on an advisory opinion issued to someone else. However, Advisory Opinion No. 12-06 has been cited in AKS investigations ever since.
When Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, it changed how physicians would be paid under Medicare and sought to transition physicians to a more value-based payment system. Physicians were incentivized to develop physician-driven payment models to improve efficiency and patient outcomes. However, existing Stark self-referral laws prohibit physicians from referring patients to an entity in which they have a financial interest. As a result, physician practices are unable to participate in many advanced alternative payment models. Stark laws, which have not been updated since their enactment 30 years ago, pose barriers to care coordination since they prohibit payment arrangements that consider volume or value of referrals or other business generated by the parties. These prohibitions stifle innovations in delivering care by inhibiting practices from incentivizing their physicians to deliver patient care more efficiently, because the practices cannot use resources from designated health services in rewarding or penalizing adherence to new clinical care pathways.
Congress recognized that the Stark law was a barrier to new health care delivery models. Congress, therefore, authorized the HHS Secretary to waive Stark self-referral and anti-kickback laws for accountable care organizations (ACOs). This waiver was not extended to physician-driven alternative payment models (APMs), that also need these exceptions to drive innovation in health care and to implement MACRA law as Congress intended.
AGA and the physician community have long sought to update Stark self-referral and AKSs. Last year, CMS proposed exceptions directed at value-based arrangements that would have allowed providers to participate in value-based arrangements while still protecting the Medicare program from potential abuses. Many of the changes that CMS proposed would have allowed physician practices to engage in value-based arrangements that would improve patient care and AGA provided comments on both the Stark and AKS proposed rules. However, CMS has not yet issued the final rules and has indicated that they will not issue a final rule on Stark which a lost opportunity to improve health care delivery.
On the legislative front, AGA supports S. 2051/H.R. 4206, the Medicare Care Coordination Improvement Act, which would provide CMS with the regulatory authority to create exceptions under the Stark law for APMs and to remove barriers in the current law to the development and operation of such arrangements. The legislation would allow CMS to waive the Stark laws for physicians seeking to develop and operate APMs similar to what Congress allowed for ACOs. The legislation would allow innovative payment models developed by gastroenterologists to be implemented in the Medicare program. Unfortunately, this legislation has received little traction in Congress.
Until meaningful regulatory and legislative reform updating both Stark and AKS occur, innovative payment models must wait and gastroenterologists and other providers will remain vulnerable to these outdated regulations. You can help us advance these issues by sharing how they impact your practice. Tell us what types of value-based arrangements you would participate in and how would they improve patient care and efficacy at Lnarramore@gastro.org.
Dr. Losurdo is the AGA’s Alternate Advisor to the American Medical Association’s CPT Editorial Panel, a member of the AGA Practice Management and Economics Committee’s Coverage and Reimbursement Subcommittee and is a partner with Elgin Gastro Endoscopy, who owns and ASC, and Managing Partner and Medical Director of Illinois Gastroenterology Group/GI Alliance, Elgin, Ill.
This story was updated on 12/11/2020.
Anti-kickback statutes (AKSs) were originally enacted in 1931 to stop Great Depression–era employers from circumventing wage provisions in federal contracts. Since its enactment, AKSs’ main focus has changed and is currently aimed at the health care industry. In addition to AKSs, Stark laws were enacted over 30 years ago to address physician self-referral of Medicare patients. Both laws comprise the government’s main tools for fighting fraud, waste, and abuse.
However, AKSs and Stark laws have not been updated to keep pace with changes in how medical practices do business and care for patients.
Over the years, additional interpretation and clarification has been issued by the Department of Health and Human Services (DHHS) and the Office of Inspector General (OIG). In DHHSs’ June 1, 2012 Advisory Opinion No. 12-06 there is guidance regarding legality of anesthesia services providers’ contract with physician-owned professional corporations or limited liability companies to provide anesthesia services. Specifically, it focused on the “company model” where owners of an ambulatory surgery center (ASC) create a separate company for anesthesia services which directly contracts with anesthesia providers and charges for the anesthesia services while the ASC charges for facility fees. Anyone with specific questions may request an advisory opinion from the OIG about the application of OIG’s fraud and abuse authorities and existing or proposed business arrangements. An OIG advisory opinion is legally binding on the requesting party and DHHS, but not on any other governmental department or agency. While advisory opinions are specific to the entity that requested it and specifically states, “This opinion may not be relied on by any persons other than [name redacted], the requestor of this opinion....” It captured the attention of the medical community. The AGA has argued that this opinion should not be interpreted to mean that all company model frameworks necessarily violate the AKSs and the OIG’s Advisor Opinions FAQ states no person or entity can rely on an advisory opinion issued to someone else. However, Advisory Opinion No. 12-06 has been cited in AKS investigations ever since.
When Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, it changed how physicians would be paid under Medicare and sought to transition physicians to a more value-based payment system. Physicians were incentivized to develop physician-driven payment models to improve efficiency and patient outcomes. However, existing Stark self-referral laws prohibit physicians from referring patients to an entity in which they have a financial interest. As a result, physician practices are unable to participate in many advanced alternative payment models. Stark laws, which have not been updated since their enactment 30 years ago, pose barriers to care coordination since they prohibit payment arrangements that consider volume or value of referrals or other business generated by the parties. These prohibitions stifle innovations in delivering care by inhibiting practices from incentivizing their physicians to deliver patient care more efficiently, because the practices cannot use resources from designated health services in rewarding or penalizing adherence to new clinical care pathways.
Congress recognized that the Stark law was a barrier to new health care delivery models. Congress, therefore, authorized the HHS Secretary to waive Stark self-referral and anti-kickback laws for accountable care organizations (ACOs). This waiver was not extended to physician-driven alternative payment models (APMs), that also need these exceptions to drive innovation in health care and to implement MACRA law as Congress intended.
AGA and the physician community have long sought to update Stark self-referral and AKSs. Last year, CMS proposed exceptions directed at value-based arrangements that would have allowed providers to participate in value-based arrangements while still protecting the Medicare program from potential abuses. Many of the changes that CMS proposed would have allowed physician practices to engage in value-based arrangements that would improve patient care and AGA provided comments on both the Stark and AKS proposed rules. However, CMS has not yet issued the final rules and has indicated that they will not issue a final rule on Stark which a lost opportunity to improve health care delivery.
On the legislative front, AGA supports S. 2051/H.R. 4206, the Medicare Care Coordination Improvement Act, which would provide CMS with the regulatory authority to create exceptions under the Stark law for APMs and to remove barriers in the current law to the development and operation of such arrangements. The legislation would allow CMS to waive the Stark laws for physicians seeking to develop and operate APMs similar to what Congress allowed for ACOs. The legislation would allow innovative payment models developed by gastroenterologists to be implemented in the Medicare program. Unfortunately, this legislation has received little traction in Congress.
Until meaningful regulatory and legislative reform updating both Stark and AKS occur, innovative payment models must wait and gastroenterologists and other providers will remain vulnerable to these outdated regulations. You can help us advance these issues by sharing how they impact your practice. Tell us what types of value-based arrangements you would participate in and how would they improve patient care and efficacy at Lnarramore@gastro.org.
Dr. Losurdo is the AGA’s Alternate Advisor to the American Medical Association’s CPT Editorial Panel, a member of the AGA Practice Management and Economics Committee’s Coverage and Reimbursement Subcommittee and is a partner with Elgin Gastro Endoscopy, who owns and ASC, and Managing Partner and Medical Director of Illinois Gastroenterology Group/GI Alliance, Elgin, Ill.
This story was updated on 12/11/2020.
Anti-kickback statutes (AKSs) were originally enacted in 1931 to stop Great Depression–era employers from circumventing wage provisions in federal contracts. Since its enactment, AKSs’ main focus has changed and is currently aimed at the health care industry. In addition to AKSs, Stark laws were enacted over 30 years ago to address physician self-referral of Medicare patients. Both laws comprise the government’s main tools for fighting fraud, waste, and abuse.
However, AKSs and Stark laws have not been updated to keep pace with changes in how medical practices do business and care for patients.
Over the years, additional interpretation and clarification has been issued by the Department of Health and Human Services (DHHS) and the Office of Inspector General (OIG). In DHHSs’ June 1, 2012 Advisory Opinion No. 12-06 there is guidance regarding legality of anesthesia services providers’ contract with physician-owned professional corporations or limited liability companies to provide anesthesia services. Specifically, it focused on the “company model” where owners of an ambulatory surgery center (ASC) create a separate company for anesthesia services which directly contracts with anesthesia providers and charges for the anesthesia services while the ASC charges for facility fees. Anyone with specific questions may request an advisory opinion from the OIG about the application of OIG’s fraud and abuse authorities and existing or proposed business arrangements. An OIG advisory opinion is legally binding on the requesting party and DHHS, but not on any other governmental department or agency. While advisory opinions are specific to the entity that requested it and specifically states, “This opinion may not be relied on by any persons other than [name redacted], the requestor of this opinion....” It captured the attention of the medical community. The AGA has argued that this opinion should not be interpreted to mean that all company model frameworks necessarily violate the AKSs and the OIG’s Advisor Opinions FAQ states no person or entity can rely on an advisory opinion issued to someone else. However, Advisory Opinion No. 12-06 has been cited in AKS investigations ever since.
When Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, it changed how physicians would be paid under Medicare and sought to transition physicians to a more value-based payment system. Physicians were incentivized to develop physician-driven payment models to improve efficiency and patient outcomes. However, existing Stark self-referral laws prohibit physicians from referring patients to an entity in which they have a financial interest. As a result, physician practices are unable to participate in many advanced alternative payment models. Stark laws, which have not been updated since their enactment 30 years ago, pose barriers to care coordination since they prohibit payment arrangements that consider volume or value of referrals or other business generated by the parties. These prohibitions stifle innovations in delivering care by inhibiting practices from incentivizing their physicians to deliver patient care more efficiently, because the practices cannot use resources from designated health services in rewarding or penalizing adherence to new clinical care pathways.
Congress recognized that the Stark law was a barrier to new health care delivery models. Congress, therefore, authorized the HHS Secretary to waive Stark self-referral and anti-kickback laws for accountable care organizations (ACOs). This waiver was not extended to physician-driven alternative payment models (APMs), that also need these exceptions to drive innovation in health care and to implement MACRA law as Congress intended.
AGA and the physician community have long sought to update Stark self-referral and AKSs. Last year, CMS proposed exceptions directed at value-based arrangements that would have allowed providers to participate in value-based arrangements while still protecting the Medicare program from potential abuses. Many of the changes that CMS proposed would have allowed physician practices to engage in value-based arrangements that would improve patient care and AGA provided comments on both the Stark and AKS proposed rules. However, CMS has not yet issued the final rules and has indicated that they will not issue a final rule on Stark which a lost opportunity to improve health care delivery.
On the legislative front, AGA supports S. 2051/H.R. 4206, the Medicare Care Coordination Improvement Act, which would provide CMS with the regulatory authority to create exceptions under the Stark law for APMs and to remove barriers in the current law to the development and operation of such arrangements. The legislation would allow CMS to waive the Stark laws for physicians seeking to develop and operate APMs similar to what Congress allowed for ACOs. The legislation would allow innovative payment models developed by gastroenterologists to be implemented in the Medicare program. Unfortunately, this legislation has received little traction in Congress.
Until meaningful regulatory and legislative reform updating both Stark and AKS occur, innovative payment models must wait and gastroenterologists and other providers will remain vulnerable to these outdated regulations. You can help us advance these issues by sharing how they impact your practice. Tell us what types of value-based arrangements you would participate in and how would they improve patient care and efficacy at Lnarramore@gastro.org.
Dr. Losurdo is the AGA’s Alternate Advisor to the American Medical Association’s CPT Editorial Panel, a member of the AGA Practice Management and Economics Committee’s Coverage and Reimbursement Subcommittee and is a partner with Elgin Gastro Endoscopy, who owns and ASC, and Managing Partner and Medical Director of Illinois Gastroenterology Group/GI Alliance, Elgin, Ill.
This story was updated on 12/11/2020.
Prepare for major changes to E/M coding starting in 2021
Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.
The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
Why were changes needed?
The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.
The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.
In sum, what are the 2021 E/M changes
While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:
1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.
2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:
- MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
- Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.
3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.
- Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
- Definitions. Defined important terms, such as “independent historian.”
- Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).
CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.
- GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).
GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
Who do these changes apply to?
The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.
What should you do?
Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.
AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429
AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.
Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.
Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.
Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.
With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.
Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.
The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
Why were changes needed?
The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.
The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.
In sum, what are the 2021 E/M changes
While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:
1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.
2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:
- MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
- Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.
3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.
- Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
- Definitions. Defined important terms, such as “independent historian.”
- Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).
CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.
- GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).
GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
Who do these changes apply to?
The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.
What should you do?
Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.
AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429
AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.
Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.
Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.
Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.
With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.
Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.
The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
Why were changes needed?
The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.
The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.
In sum, what are the 2021 E/M changes
While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:
1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.
2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:
- MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
- Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.
3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.
- Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
- Definitions. Defined important terms, such as “independent historian.”
- Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).
CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.
- GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).
GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
Who do these changes apply to?
The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.
What should you do?
Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.
AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429
AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.
Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.
Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.
Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.
With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.