Starting January 1, the Centers for Medicare and Medicaid will reduce the conversion factor (CF), decreasing the rate from $34.61 to $33.06 – $1.55 less than the 2022 amount. This final rule has many providers reeling from the expected impact on their business, especially since they’re recovering from the pandemic pinch and inflation. On the flip side, CMS hopes to bolster behavioral health, chronic pain management, and substance use disorders by aligning payment and coverage with the CMS Behavioral Health Strategy that seeks to remove barriers to care and services. Like 2022 itself, the rule is a mixed bag. We’ll cover industry reaction in this blog, plus we’ll share tips for accurately coding E/M for time, provide coding errors that be red flags to auditors, and clear up specific codes that can be confusing.
If you thought that CMS wouldn’t follow through on its conversion factor (CF) reduction proposals — especially since Medicare providers are still recovering from pandemic fallout and dealing with inflation — think again.
Context: On Nov. 1, the Centers for Medicare and Medicaid Services (CMS) issued the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) final rule. The 2,953 document covers a wide range of topics from Part B payment and coverage policies to Medicare Shared Savings Program (MSSP) changes to the latest updates on COVID-19 interim rules. The new rule was added into the Federal Register on Nov. 18, 2022.
The CY 2023 MPFS final rule is a mixed bag of policy highs and lows. Among the high points, CMS follows through on its promises to bolster behavioral health, chronic pain management, and substance use disorders by aligning payment and coverage with the CMS Behavioral Health Strategy, a five-goal initiative that “seeks to remove barriers to care and services,” the agency says in a release.
“Access to services promoting behavioral health, wellness, and whole-person care is key to helping people achieve the best health possible,” says CMS Administrator Chiquita Brooks-LaSure in a release. “The Physician Fee Schedule final rule ensures that the people we serve will experience coordinated care and that they have access to prevention and treatment services for substance use, mental health services, crisis intervention, and pain care.”
The “whole-person approach” translates to Medicare updates in other areas, too. CMS also offers a boost to dental services, clarifies telehealth services post-COVID-19-PHE, and refines preventative vaccination administration payment policies, according to the MPFS final rule.
“The Biden-Harris Administration is committed to expanding access to vital prevention and treatment services,” explains HHS Secretary Xavier Becerra in a release. “Providing whole person support and services through Medicare will improve health and wellbeing for millions of Americans and even save lives.”
One of the less popular MPFS changes surrounds CMS’ decision to reduce the CF in 2023.
CMS had originally proposed in July — to industry-wide consternation — to cut the CF by $1.53 for CY 2023, decreasing the rate from $34.61 to $33.08. But, instead of going with that change, the agency decided to cut the CF even more in the final rule to $33.06 or $1.55 less than the 2022 amount.
After the proposed CF reduction was announced, industry organizations urged CMS to reconsider such a detrimental pay cut. But that advocacy didn’t work, and now healthcare leaders are asking Congress to get involved.
Physicians are already feeling the heat and the CF cut would makes their burden heavier. According to a public statement issued by AMA President Jack Resneck Jr., MD, “Unless Congress acts by the end of the year, physician Medicare payments are planned to be cut by nearly 8.5 percent in 2023 — partly from the 4 percent PAYGO sequester — which would severely impede patient access to care due to the forced closure of physician practices and put further strain on those that remained open during the pandemic.”
Industry leaders across the healthcare spectrum predict that the reduction will reduce access to care.
Reminder: In the CY 2022 final rule, which came out in November 2021, CMS cut the CF by $1.30, reducing it from $34.89 to $33.59. That change coincided with the expiration of the 3.75-percent CF increase that had originally been a provision under the Consolidated Appropriations Act, 2021 (CAA). Last year’s CF saga continued when Congress stepped in with the Protecting Medicare and American Farmers from Sequester Cuts Act on Dec. 10, 2021 and added a three percent increase back into the CF equation (see Medicare Compliance & Reimbursement, Vol. 48, No. 1).
At press time, Congress hadn’t made a move to thwart the impending CF cut — yet. Medicare Compliance & Reimbursement will continue to monitor developments on this policy.
See the full document on the Federal Register website.
Even for the most seasoned coders, determining the level of an evaluation and management (E/M) encounter using total time consistently can be confusing. Plus, your Part B practice may still be working out the claims issues in relation to using the 2021 updates to the CPT® Office and Other Outpatient Services codes. And now, these E/M rules are about to extend to hospital and inpatient E/M services, so there’s no better time to clear up the confusion.
Per the 2021 CPT® guidelines, the full list of activities that you can use to count time includes:
One of the most common misconceptions on reporting an E/M based on time is that a provider is required to document the time spent on each specific task associated with the visit. Instead, the provider needs to document the total time personally spent on the activities listed above on the date of the encounter.
Rounding up is an E/M coding mistake that will surely raise red flags to an auditor. Rounding up a few minutes on each encounter, turning 16 minutes into 20, or 25 into 30, may not seem like a big deal, but it can be.
Think about it this way: When physicians round up on every patient, it has a dramatic effect by the end of the day. Adding an extra five minutes to each patient could end up looking like each physician spent hours longer at the clinic than they really did. Inflating time, whether intentional or not, is not best practice — in fact, compliance enforcement could consider it abuse or fraud, both serious and costly.
Per 2022 CPT® E/M guidelines, if a physician and other qualified healthcare professional (QHP), such as a nurse practitioner (NP) or physician assistant (PA), shared or split the time assessing and managing the patient on the date of the encounter, that time is summed to define total time. However, only distinct time should be summed for shared or split visits (i.e., when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).
For example, if a patient comes in for a follow-up and sees an NP for 10 minutes to start to evaluate any new patient complaints. The patient then consults with the physician for 15 minutes about the problem and a new treatment plan. Time spent in the room together counts only once. The total time is 25 minutes.
Documenting time correctly is not only best practice — it often counts in favor of the physician. The AMA defines time for E/M coding as the total time (based on minutes) the provider spends on the date of service during which a provider personally rendered services related to the patient’s care, even if the times are not consecutive. Sometimes physicians forget to document all their time.
If those forgotten services are accounted for in the record and performed on the date of the encounter (for example, reviewing labs after the encounter on the same date of service [DOS]), you can justify that time if an auditor questions it. Be careful not to double count time if the physician and a QHP spend time discussing a problem outside of the room after the encounter.
Are you missing time a provider spends with a patient? This could be the case when your provider documents how many minutes they spent with the patient, but don’t include the time spent preparing to see them. This is common for physicians who are still accustomed to documenting in-office visits based only on face-to-face time.
On the other hand, sometimes practices mistakenly count services twice. For example, for many minor surgeries, the CPT® code for the procedure includes time for pre-procedure evaluation, so counting that time toward time used to report an E/M code would be double counting and result in the physician getting paid twice for the same time. Pay close attention to which procedure codes include pre-procedure E/M. Also, pay close attention to the documentation.
Using time to level an encounter is not only perfectly legitimate, it’s also often in the physician’s best interest to code this way. The documentation must be precise to justify the time spent. When auditors perform time-based audits, they compare the time a provider worked against aggregated visit time. If the coded time adds up to more than the time worked, the auditor will question the discrepancy.
Fixing these issues before they become bigger issues might be a matter of more precise time reporting. Rounding up, forgetting to document same-day non-face-to-face time, and misrepresenting other billable services will all lead to inconsistencies during an audit. The best thing to do is study the patterns of the practice to see if there are any anomalies. As always, be sure to keep an open line of communication between your coding department and your physicians.
If you find coding low back pain challenging, you’re not alone. You need a lot of information to select the most appropriate diagnosis code — and that can be difficult. Bolster your coding caliber with three codes in the M54.5- family.
Consider this guidance and boost your coding specificity.
“Chronic low back pain frequently stems from the vertebrae itself, which is referred to as vertebrogenic back pain. Pain that originates at the disc is called discogenic,” as defined by Neurosurgery One. To help coders report patient care to the highest specificity, ICD-10 2022 divided M54.5 (Low back pain) into three new codes that take this definition into account:
Code M54.50 includes loin pain and low back pain (lumbago) not otherwise specified (NOS), M54.51 includes low back vertebral endplate pain, and you should use M54.59 for specified low back pain that’s not in the vertebrae. It’s very possible, especially at a first encounter, that the exact source of the pain won’t be known, which will likely lead to the unspecified code M54.50.
The accurate diagnosis code depends primarily on the level of documentations identifying the site and type of pain. It’s also important to notice the following as Excludes1 diagnoses for M54.5- codes:
Lumbago is a general term often used for pain in the lower back, so pay attention to the patient record carefully, and query the provider if questions arise.
Adding an unnecessary G89.- (Pain, not elsewhere classified) code to a back pain diagnosis is an easy mistake to make, especially if you follow ICD-10-CM Official Guidelines, Section I.C.6.b.1(b) (i), which states, “Codes from category G89 may be used in conjunction with codes that identify the site of pain (including codes from chapter 18 [Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)]) if the category G89 code provides additional information. For example, if the code describes the site of the pain, but does not fully describe whether the pain is acute or chronic, then both codes [a G89 code and site-specific code] should be assigned.”
Consistent with that guideline, M54.5- is on the long list of Excludes2 notes under G89.-. That means low back pain is a separate diagnosis from G89.-, and G89.- should not be used for low back pain per se. But if the patient has both low back pain and pain not elsewhere classified, or if a category G89.- code provides additional information, then codes M54.5- and G89.- may both be used.
If the patient’s back pain is a result of an injury or the side effect of an invasive medical procedure, code assignment will then be subject to ICD-10 guideline I.C.13.b., which states that recurrent bone, joint, or muscle conditions, including those that are the result of a healed injury, are usually found in Chapter 13, Diseases of the musculoskeletal system and connective tissue (M00-M99).
The guideline goes on to state “any current, acute injury should be coded to the appropriate injury code from chapter 19 [Injury, poisoning and certain other consequences of external causes (S00-T88)]. Chronic or recurrent conditions should generally be coded with a code from chapter 13. If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.” In other words, if the source of the current, acute pain is known, and that source is an injury (for example, S33.5XXA (Sprain of ligaments of lumbar spine, initial encounter)), the injury itself is the most appropriate condition to code in these instances.
Pain is generally acute or chronic. The cause of acute pain is generally known. The cause of chronic paint is generally more complicated. Whether the pain is acute or chronic is not up to the coder’s interpretation. Those distinctions are made by the provider and they need to be documented as specifically as possible.
As for which code to rely on when reporting acute or chronic low back pain specifically, the key is to not overcomplicate things. Keep it simple. You won’t always find a distinction between acute and chronic pain in the patient record, but the provider should document as much detail as possible because it always leads to the ability to code to the highest specificity. The more details, the better — for more accurate coding and fewer reasons for denial.
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