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2020 Medicare Physician Fee Schedule and CPT Code Changes Impacting PM&R Practice

Effective January 1, 2020, several changes have been made to payment policy, coding, and reimbursement.  Several new codes have been added to the CPT codebook and the Centers for Medicare and Medicaid Services (CMS) has approved new payment rates for several physiatry services as published in the 2020 Medicare Physician Fee Schedule (MPFS).  The fee schedule, updated annually, includes payment policy and reimbursement information for all codes billed to Medicare Part B.  Your Academy monitors the annual proposed changes to the fee schedule and submits comments which CMS considers in its final rulemaking process. 

PM&R 2020 Coding Changes and Payment Updates

The following is a summary of the coding and reimbursement changes affecting physiatrists effective January 1, 2020.  The 2020 conversion factor, which is used to determine payment for Medicare services, is finalized at $36.0896, an increase of approximately $0.05.  Note that total payment listed in this article is rounded to the nearest whole dollar and reflects national payment in the non-facility setting.  Practice expense RVUs are also listed for the non-facility setting only.  Payment will differ based on locale.  Also note that payment is specific to Medicare Part B; commercial payer rates will differ.

New Codes for Genicular and Sacroiliac Joint Injection and Destruction/Ablation

One of the most significant changes for 2020 is the creation of four new CPT codes for procedures physiatrists regularly perform.  Two new codes have been added to describe the injection or destruction of genicular nerves.  An additional two codes have been added to describe the injection or destruction of the nerves innervating the sacroiliac joint.   The creation of these codes depended on countless hours of work by our member volunteers who collected supporting evidence, created code applications, reviewed member survey data regarding appropriate values, and argued in support of these services at the CPT and RUC meetings.  A huge thank you to our CPT and RUC volunteers for their hard work!

Code

Descriptor

Work RVU

PE RVU

Total RVU

Total Payment

64451

Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)

1.52

4.32

5.99

$216

64454

Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed

1.52

4.38

6.05

$218

64624

Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

2.50

8.83

11.54

$416

64625

Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)

3.39

10.43

14.14

$510

New Codes for Dry Needling

Two new codes have been added to the CPT codebook describing dry needling.  These services are considered “non-covered” under Medicare.  However, CMS has assigned a value to the services as a means of guiding private payors who may choose to pay for dry needling.  Please check with your payor to determine if they will reimburse for this service. 

Code

Descriptor

Work RVU

PE RVU

Total RVU

Total Payment

20560

Needle insertion(s) without injection(s); 1 or 2 muscle(s)

0.32

0.39

0.74

$27

20561

Needle insertion(s) without injection(s); 3 or more muscles

0.48

0.57

1.10

$40

 

Somatic Nerve Injection Codes – Changes to Payment

The CPT and RUC recently reviewed the somatic nerve injection family of codes and recommended new language and values for these services.  Code language has been clarified to indicate that regardless of how many of a certain type of injection you perform, each code is billed only once.  Further, a table has been added to the CPT codebook to clarify which injection codes include imaging and which codes require separate billing of imaging if performed.  Additionally, the codes for intercostal nerve injections have been updated to include an add-on code when injections are provided at more than one level (see codes 64420 and 64421).  Many of the somatic nerve injection codes had not been reviewed by RUC since the 1990s.  Unfortunately, the reimbursement for many of these services will decrease as a result of this revaluation (some codes retained their current value).  Note that while the entire family of codes has been reviewed, the table below only reflects those procedures which PM&R bills with any regularity.

Code

Descriptor

Work RVU

PE RVU

Total RVU

Total Payment

64400

Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)

0.75

2.12

3.05

$110

64405

Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve

0.94

0.92

2.07

$75

64417

Injection(s), anesthetic agent(s) and/or steroid; axillary nerve

1.27

2.51

3.89

$140

64418

Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve

1.10

1.20

2.42

$87

64420

Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level

1.08

1.66

2.85

$103

+64421

Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (list separately in addition to code for primary procedure)

0.50

0.42

0.97

$35

64425

Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves

1.00

2.08

3.19

$115

64430

Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve

1.00

1.46

2.57

$93

64445

Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve

1.00

2.48

3.57

$129

64450

Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch

0.75

1.34

2.18

$79

 

Intrathecal Pump Analysis and Programming Codes – Changes to PE

Practice expense for the intrathecal pump and programming codes was reviewed by the RUC.  Based on this re-review, CMS has implemented decreased practice expense values for these codes resulting in decreased payment overall.

Code

Descriptor

Work RVU

PE RVU

Total RVU

Total Payment

62367

Electronic analysis of programable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status; without programming or refill

0.48

0.38

0.92

$33

62368

Electronic analysis of programable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status; with reprogramming

0.67

0.53

1.29

$47

62369

Electronic analysis of programable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status; with reprogramming and refill

0.67

1.97

2.73

$99

62370

Electronic analysis of programable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status; with reprogramming and refill (requiring skill of a physician or other qualified health care professional)

0.90

1.84

2.83

$102

 

Ultrasound of Extremity – Changes to PE

As previously reported in 2018 and 2019, practice expense for ultrasound code 76881 has changed.  In the 2018 MPFS final rule, CMS finalized a proposal to revise practice expense inputs for both ultrasound codes.  For the complete joint ultrasound code, 76881, CMS determined that this service is no longer typically performed in a dedicated ultrasound room or using a PACS workstation.  Because of these changes, CMS finalized a significant decrease to practice expense, which will be implemented over a series of years beginning in 2018.  In 2020, total payment for 76881 has decreased by approximately $11.  A similar cut is expected for 2021.  Changes to 76882 for 2020 total less than $0.50. 

Code

Descriptor

Work RVU

PE RVU

Total RVU

Total Payment

76881

Ultrasound, complete joint (ie, joint space and periarticular soft-tissue structures), real-time with image documentation

0.63

1.53

2.19

$79

76882

Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon(s), muscle(s), nerve(s), other soft-tissue structure(s), or soft-tissue mass(es), real-time with image documentation

0.49

1.09

1.61

$58

 

New Codes for Principal Care Management

CMS finalized payment for two new codes for “principal care management.”  The codes describe work done over the course of a calendar month to care for patients with a single high-risk disease.  Payment reflects work done in 30 minutes or more to create and maintain a care plan and coordinate care for the patient.  Patient visits and any procedures performed on the patient would be separately billable.  These codes were developed by CMS and therefore are not found in the CPT codebook at this time.  Instructions for how the codes are intended to be used can be found in the MPFS Final Rule, however we anticipate that CMS will publish additional guidance on these codes in the form of an online article. 

The two codes are distinguished based on provider: code G2064 is paid at a higher rate and requires 30 minutes of physician or other qualified healthcare professional time per calendar month; code G2065 is paid at a lower rate and requires clinical staff time only. 

The services require the following elements:

  • One chronic condition lasting at least 3 months, which is the focus of the care plan
  • The condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization
  • The condition requires development or revision of disease-specific care plan
  • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

 

Code

Descriptor

Work RVU

PE RVU

Total RVU

Total Payment

G2064

Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified healthcare professional time per calendar month

1.45

0.99

2.55

$92

G2065

Comprehensive care management services for a single high-risk disease services, e.g., Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

0.61

0.44

1.10

$40

 

2020 Policy Changes Impacting PM&R

Several changes were made to CMS and CPT policy which will impact PM&R coding, billing and documentation in 2020. 

Modifier 50 – Bilateral Procedures and Add-on Codes

Effective January 1, 2020, the CPT codebook is implementing new guidelines for the billing of modifier 50 for bilateral procedures in conjunction with add-on codes.  Effective this year, add-on codes cannot be billed with modifier 50 to denote bilaterality.  Instead, when the add-on procedure can be reported bilaterally and is performed bilaterally, the add-on code should be reported twice.  Coders should also review the add-on code descriptor, guidelines and parenthetical instructions for additional information if available. 

Physician Supervision for Physician Assistant (PA) Services

In the 2020 MPFS Final Rule, CMS finalized a proposal designed to enable PAs to practice more broadly.  AAPM&R opposed this proposal in our comment letter to the MPFS proposed rule.  The Academy comment highlighted concerns about patient care resulting from lack of oversight of PA services.  Effective January 1, 2020, rather than restricting PAs to a national Medicare supervision requirement, CMS will allow PAs to provide professional services according to state law and state scope of practice rules set by the state the PA is practicing in.  For states with no explicit law or scope of practice rules, CMS has defined supervision as “a process in which a PA has a working relationship with one or more physicians to supervise the delivery of the health care services.  Such physician supervision is evidenced by documenting at the practice level that PA’s scope of practice and the working relationships the PA has with the supervising physician/s when furnishing professional services.” 

CMS Proposes Retraction of Original 2021 E/M Plan in Favor of New CPT Proposal and RUC Recommendations

On Monday July 29 the Centers for Medicare & Medicaid Services (CMS) released the 2020 Physician Fee Schedule Proposed Rule which includes revisions to previously announced proposals for 2021 office/outpatient evaluation and management (E/M) visits.  Last July, CMS proposed collapsing payment for office/outpatient E/M visits, creating a single payment rate for level 2-5 visits.  Your Academy actively opposed this proposal through several comment periods and participated in an AMA Current Procedural Terminology (CPT) Panel process to create an alternative E/M coding structure to meet the intention of CMS’s proposal without resulting in reduced payment.  Your Academy also actively participated in the AMA Relative Value Scale Update Committee (RUC) process to value the revised E/M codes.  We are pleased that CMS accepted both the CPT revisions as well as the RUC recommended values.

YX8A2024

This proposal reflects the hard work of your Academy’s CPT and RUC advisors as well as the Reimbursement and Policy Review Committee who advocated to CMS and worked with the AMA on the alternative proposal throughout 2018 and 2019.

Click here to view a timeline of the efforts or click the image below to enlarge.

em timeline

Key Elements of the 2021 E/M Proposal

CMS identified burden reduction as a primary goal of its original proposal for 2021.  The updated proposal includes many elements that also seek to achieve this goal while reflecting current medical practice.  Key elements include:

  • Elimination of history and physical as elements for code selection – pertinent history and physical are still taken/performed, but physicians won’t use this information to determine the E/M level.
  • Code selection will be based on level of Medical Decision Making (MDM) or based on Total Time – revised definitions for MDM and Total Time are included in the 2021 CPT E/M guidelines.
  • Elimination of code 99201
  • Creation of a new shorter prolonged services code – the new code captures physician time in 15-minute increments and can be reported with 99205 and 99215.

Additional information about the revised code structure can be found on the AMA website.

Add-On Code for Single, Serious, or Complex Chronic Conditions

In addition to the above described changes for 2021, CMS is proposing to create an add-on code to be used only with office/outpatient E/M services.  This code is intended to capture the per-visit work inherent to caring for patients added complexity.  CMS notes in the proposed rule that “we believe the typical visit described by the revised code set still does not adequately describe or reflect the resources associated with primary care and certain types of specialty visits.” 1

The new add-on code is described as:

GPC1X – 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). 

Proposed 2021 Office and Outpatient E/M Payment

CMS has proposed accepting the RUC recommended values and times for the updated E/M code set.  This includes an increase in work RVU value for most codes (as described in the table below).  The increased RVUs may result in increased payment in 2021 for certain codes.  However, the proposed rule does not indicate a conversion factor for 2021.  To maintain budget neutrality, CMS will likely decrease the conversion factor in 2021 to account for the increase in RVUs.  AAPM&R will monitor proposals related to this change and inform members when information becomes available.  

HCPCS Code

Current Phys Time

Current Work RVU

RUC/Proposed Phys Time

RUC/Proposed Work RVU

99201

17

0.48

N/A

N/A

99202

22

0.93

22

0.93

99203

29

1.42

40

1.6

99204

45

2.43

60

2.6

99205

67

3.17

85

3.5

99211

7

0.18

7

0.18

99212

16

0.48

18

0.7

99213

23

0.97

30

1.3

99214

40

1.5

49

1.92

99215

55

2.11

70

2.8

GPC1X (add-on code)

N/A

N/A

11

0.33

 

Conclusion and Anticipated Impact of the 2021 E/M Proposal

CMS has estimated that the overall impact of the 2021 E/M proposal (including the proposed add-on code) will be -2% for Physical Medicine.  Academy staff is still analyzing this impact estimate, but it is suspected that this negative impact is based on an understanding that Physical Medicine will not bill the add-on code.  Contrary to the CMS estimate, we believe that for our members who bill higher-level office and outpatient E/M visits, this proposal will result in a positive impact.  We also believe certain Academy members will bill the add-on code.  Academy staff is continuing to review the proposed rule.  We will update members as new details about the proposal are identified. 

About MPFS

Medicare payment for physicians, and some non-physician practitioners (NPPs), is based on set rates under Medicare Part B. The system for payment, known as the Medicare Physician Fee Schedule (MPFS), is used when paying for: professional services of physicians and some NPPs; covered services incident to physicians’ services (other than certain drugs covered as incident to services); diagnostic tests (other than clinical laboratory tests); and radiology services. The MPFS also addresses various quality issues, fraud and abuse issues, and other issues that impact physicians. CMS updates the MPFS regulations annually, with comment periods open prior to implementation of the final rule.