August 05, 2019
3 min read

CMS takes E&M code restructuring off the table in proposed rule for physician pay

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Robert Blaser

Nephrologists will likely see minor increases next year in payments for 14 of the 17 billable inpatient and outpatient dialysis services they provide; but the bigger news, according to an analysis of the proposed Medicare Physician Fee Schedule for 2020, is a decision by CMS to table a plan to blend a number of evaluation and management codes that would have had a negative impact on physician pay.

“The Renal Physicians Association (RPA) was pleased to see that CMS appears to have listened to nephrologists’ concerns and did not compress the evaluation and management code payment levels as proposed last year,” Robert Blaser, director of public policy for the advocacy group, said in an email to Healio/Nephrology.

In his analysis of the proposed rule, Blaser said CMS agreed to implement recommendations from the AMA's Relative Value Update Committee on outpatient E&M codes, “and thus it appears that CMS’ proposal from 2018 to collapse payment for these code families has been abandoned, much to the relief of organized medicine.” CMS would also set the 2020 conversion factor at $36.09, a $0.05 increase over the 2019 value of $36.04, “and resulting mostly from this, nephrology as a specialty will experience a 1% reimbursement increase for 2020 if the rule is finalized as proposed,” Blaser said.

Blaser noted the following changes for payment codes used by nephrologists:

  • High-volume dialysis code, CPT code 90960 (adult four-visit MCP), has a proposed 2020 payment increase of $2.93, for a payment of $291.96, and 90966 (adult home hemodialysis) is increased by $1.78 for a payment of $243.97;
  • CPT codes 90935 (hemodialysis, single evaluation) will be reduced 0.5%, 90951 (ESRD monthly services, four visits, patients younger than 2 years old) will be reduced 0.2% and 90968 (ESRD daily dialysis, patients aged 2 to 11 years) will be reduced 2.1%; and
  • CMS is also proposing to allow billing of the transitional care management (TCM) codes (CPT codes 99495 and 99496) in conjunction with the adult outpatient dialysis codes (CPT codes 90960, 90961, 90962, 90966 and 90970), Blaser said. “Billing the TCM codes for these services to this point has been prohibited. This decision is based on the agency’s valid perception that the services are underutilized,” he said.

Additionally, CMS proposes to create new codes for principal care management services.

Vascular access codes unchanged

In addition, Blaser said CMS did not implement site-neutral payments in the Hospital Outpatient Prospective Payment System/Ambulatory Surgical Center Payment Systems (HOPPS/ASC) proposed rule for ambulatory surgical center. That preserved reimbursement for access procedures.

“That is great news for dialysis access care,” he told Healio/Nephrology.

Specifically, CMS did not apply the office-based designation to the high-volume dialysis access codes (both are balloon angioplasty services), said Blaser in his analysis, “so the site neutrality policy proposed for implementation in 2019 that reduced reimbursement for these services by 55% and 54%, respectively was not even proposed this year.”

“All in all, the payment rules contained good news and made no mischief for the nephrology specialty,” Blaser told Healio/Nephrology.

In a press release about the proposed rule, CMS said the policy changes in the MFS and the Quality Payment Program, which rewards physicians for meeting certain quality criteria, “are aimed at reducing burden, recognizing clinicians for the time they spend with patients, removing unnecessary measures and making it easier for them to be on the path toward value-based care. This proposed rule builds on the Trump administration’s efforts to establish a patient-driven healthcare system that focuses on better health outcomes and is projected to save 2.3 million hours per year in burden reduction.”

Opioid treatment covered

This proposed rule also includes new Medicare coverage to pay opioid treatment programs for delivering treatment to patients suffering from opioid use disorder. CMS is proposing a new monthly bundled payment to practitioners for management and counseling involving treatment for patients with the disorder. – by Mark E. Neumann


Disclosure: Blaser reports no relevant financial disclosures.