With the new year approaching, it’s time to take a look at the Medicare Physician Fee Schedule (MPFS) Final Rule that takes effect January 1, 2022 to make sure everyone is up to speed on the changes. But that’s not the only thing coming during the colder months. With wintry weather comes more patients in your waiting room with cold, flu, and general respiratory symptoms. Check out our tips for coding them accurately so your claims are reimbursed promptly.
The Medicare Physician Fee Schedule (MPFS) Final Rule was issued on November 2, 2021 by the Centers for Medicare & Medicaid Services (CMS). This rule, issued annually to announce policy changes for Medicare, takes effect January 1, 2022.
A number of factors impact Medicare payment rates including adjustment to the Conversion Factor, relative value units (RVUs) assigned, and geographic adjustments (i.e., the geographic practice cost index (GPCI)). The newest final rule includes updates to the Practice Expense RVUs to account for increasing clinical labor pricing. However, the Conversion Factor was reduced to $33.59 – a $1.30 reduction from 2021. Based on the RVUs, national allowables will be as follows:
|Code||Total RVUs||National allowable||Estimated total RVUs||Estimated national allowable||Difference in dollars||% Difference|
Final payments may also be impacted by the two percent Medicare sequestration which will go back into effect without Congressional intervention.
Not all services are part of the physician fee schedule (e.g., labs), so these rates will not be impacted.
CMS will increase the allowable to administer influenza, pneumococcal, and hepatitis B virus vaccines to $30 from an average rate of $17.63 in 2021. This is for codes G0008 (influenza), G0009 (pneumococcal), and G0010 (hepatitis B). The amount is subject to a geographic adjustment.
COVID-19 vaccine administration and monoclonal antibody infusion services will remain at the current rates until January 1 of the year following the end of the Public Health Emergency (PHE). The PHE remains in place through January 16, 2022 unless or until it is extended again.
Split (or shared) evaluation and management (E/M) services are when the level of service is determined by documentation from both the physician and a nonphysician practitioner (NPP) for a date of service.
In the office setting, the incident-to guidelines must be met. In 2022, CMS will officially limit shared visits to an institutional setting only.
CMS will cover telehealth services added during the COVID-19 PHE until the end of 2023 while they continue to consider a permanent policy change. The originating site fee, Q3014, for practices that use load sharing will have a small increase in 2022 to $27.59 from $27.02.
In recognition of current clinical practice and the evolving role of non-physician practitioner (NPPs), CMS will be allowed to make direct payment to physician assistants (PAs). Currently, payments are only allowed to the employer of the PA. Effective January 1, 2022, PAs have additional options to bill Medicare directly for their professional services or even incorporate with other PAs and bill Medicare for PA services.
While code descriptors are never big news, one key change to a low-level office/outpatient (E/M) service code descriptor coming into effect on January 1, 2022 could be a welcome change in your clinic.
The revision is the level one office/outpatient E/M code for established patients. In 2022, the descriptor will read 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional.).
The 2021 descriptor is: 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.)
What this change means
The phrase “Usually, the presenting problem(s) are minimal.” has been deleted to bring the descriptor for 99211 more in line with the rest of the office/outpatient evaluation and management (E/M) codes. The descriptors for those codes prior to 2021 all included a sentence that read, “Usually, the presenting problem(s) are…,” and now they don’t.
With the phrase removal, 99211’s descriptor is now more synched with the other office/outpatient E/Ms: 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).
This change eliminates a source of confusion as to what is a minimal problem and what is not.
Even with the change, 99211 still represents an E/M service provided by clinical staff as opposed to a physician or other qualified healthcare professional who may report higher levels of E/M services. Services described by 99211 must be medically necessary (i.e., clinically indicated) and be part of a plan of care by a physician or other qualified healthcare professional. This is why 99211 is not reportable for providing a service at a patient’s request rather than as part of an established plan of care.
With wintry weather approaching, urgent care waiting rooms are about to be inundated with sniffles — and more severe symptoms. While clinicians and labs spend time figuring out whether each symptom is indicative of COVID-19 or another respiratory illness, coders may be digging through the guidelines to know how to best choose a code, whatever the diagnosis.
Use this comprehensive guide to coding wintertime respiratory conditions as a quick and easy reference.
Tip 1: Key Instruction for J Codes
One of the trickiest parts of coding respiratory system conditions is remembering the note at the beginning of ICD-10 Chapter 10 telling you that “when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.” Remember: This note applies to all the codes in the section.
To avoid a coding error with respiratory conditions, refresh your knowledge of the respiratory system. If your pediatrician documents both nasopharyngitis and chronic pharyngitis, for example, knowing that the pharynx is anatomically lower in the body’s system than the nasal passages will lead you to correctly code J31.2 (Chronic pharyngitis) on its own.
And don’t forget additional code when applicable: The entire J00-J99 codes section carries a “Use additional code” instruction telling you to use codes such as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)), F17.- (Nicotine dependence), or Z72.0 (Tobacco use) for any associated tobacco exposure, dependence, or use.
Tip 2: Excludes1 Instructions for the J00-J06 Codes
Next, coding acute upper respiratory infections (URIs, ICD-10 codes J00-J06) comes with its own set of challenges in the form of the numerous Excludes1 instructions.
One instruction that applies to all the J00-J06 tells you to code J44.0 (Chronic obstructive pulmonary disease with (acute) lower respiratory infection) if a patient is diagnosed with both chronic obstructive pulmonary disease (COPD) and an acute lower respiratory infection along with one of the conditions from the group.
This is one of numerous Excludes1 instructions for many of the J00-J06 code subgroups, most notably the ones for J00 (Acute nasopharyngitis [common cold]). The instructions also include a lot of conditions that are typically seen with the common cold, notably the pharyngitis codes such as acute pharyngitis (J02.-), and acute sore throat NOS (not otherwise specified), pharyngitis NOS, and sore throat NOS that all code to J02.9 (Acute pharyngitis, unspecified).
Tip 3: I.C.10.c. for Influenza
Coding for the J09.- (Influenza due to certain identified influenza viruses) and J10.- (Influenza due to other identified influenza virus) code groups is another tricky, chapter-specific guideline that tells you to “code only confirmed cases of influenza.” The guideline also tells you that confirmation “does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus.”
Instead, the guideline says that “coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.” And for cases of influenza recorded by the provider as “‘suspected,’ ‘possible,’ or ‘probable,’” ICD-10 instructs you to assign an appropriate influenza code from category J11 (Influenza due to unidentified influenza virus).
What this means: This is one of those times when the chapter-specific guideline will override guideline IV.H, which instructs you not to “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty” when coding and reporting diagnoses in outpatient settings.
So, a patient reports to your pediatrician with fever, muscle pain, sore throat, earache, cough, and a runny nose. Your pediatrician documents that the patient has suspected influenza with otitis media.
A provider’s clinical judgment and experience are as valid as any test result for some conditions like flu.
Tip 4: New Codes for Coughs
Other codes that are sure to get a workout this winter are the new cough codes that are effective now. This newly expanded code group includes codes for different levels of severity, including:
Remember: Use R05.3 if your pediatrician documents persistent cough, refractory cough (a cough that persists despite treatment), or unexplained cough, as ICD-10 has added all three as synonyms for this code.
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