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ICD-10 Changes for 2021

The ICD-10-CM update for 2021 became effective on October 1, 2020. The 2021 edition contains 72,616 codes that includes 490 additions, 47 code revisions and 58 deletions. There are also 162 new headers along with 7 deletions and 5 revisions. The ICD-CM code set in the United States is maintained by the ICD Coordination and Maintenance Committee. This committee includes representatives from the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). This committee reviews all requests for changes or additions to the code set. The Director of NCHS and the Administrator of CMS make the final coding data set decisions.

New codes were added in Chapter 6 (Diseases of the Nervous System (G00-G99)) and Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)). Both chapters have revisions to inclusion codes, terminology and instructions. Although the codes will appear in your EHR, the changes in terms and instructions likely will not appear in your EHR code selection process. However, a digital copy of the ICD manual is available in most EHR systems.

The subcategory G96.0 (Cerebral spinal fluid leak) has been expanded to include the following new codes:

  • G96.00 Cerebrospinal fluid leak, unspecified
  • G96.01 Cranial cerebrospinal fluid leak, spontaneous
  • G96.02 Spinal cerebrospinal fluid leak, spontaneous
  • G96.08 Other cranial cerebrospinal fluid leak
  • G96.09 Other spinal cerebrospinal fluid leak

Additional codes were added to select subcategories in the following categories to indicate “other specified site”.

  • M05 Rheumatoid arthritis with rheumatoid factor
  • M06 ChangeM06 Other rheumatoid arthritis
  • M08 ChangeM08 Juvenile arthritis
  • M19 Other and unspecified osteoarthritis
  • M24 Other specific joint derangements
  • M25 Other joint disorder, not elsewhere classified

Two new subcategories were added to M26.6 (Temporomandibular joint disorders) and both include options for laterality. The new subcategories are:

  • M26.64 Arthritis of temporomandibular joint
  • M26.65 Arthropathy of temporomandibular joint​

Other ICD Chapters also contain changes. Those of most interest to Pain Management Physicians are noted here. ICD code R51 (Headache) was deleted in Chapter 18 (Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified) and replaced with two new codes:

  • R51.0 Headache with orthostatic component, not elsewhere classified
  • R51.9 Headache, unspecified

Changes in Chapter 19 (Injury, poisoning and certain other consequences of external causes) includes the addition of new codes and subcategories under T40.4 (Poisoning by, adverse effect of and underdosing of other synthetic narcotic). The new subcategories are T40.41 (fentanyl or fentanyl analogs) and T40.42 (tramadol). Each contains new codes that match the current code distinctions found within T40.4.

Multiple new codes were added to Chapter 5 (Mental, behavioral and neurodevelopmental disorders) related to substance abuse disorders. The changes primarily add new subcategories and codes related to withdrawal. Codes in categories F10 (Alcohol related disorders), F13 (Sedative, hypnotic, or anxiolytic related disorders) and F19 (Other psychoactive substance related disorders) have a 6th characters describing manifestations of withdrawal.

The new codes and instructions are effective October 1, 2020 through September 30, 2021.

AMA Releases New Code for Use During the Public Health Emergency

On September 8, the American Medical Association (AMA) released a new code to report the additional practice expenses incurred during a public health emergency (PHE) that is over and above those usually included in a medical visit or service. The code accounts for the additional supplies, materials, and clinical staff time associated with evaluation, management and procedural services provided during the current PHE. 

 Code 99072 is effective immediately and reads:

Additional supplies, materials, and preparation time required and provided by the physician or other qualified health care professional and/or clinical staff over and above those usually included in an office visit or other service(s), when performed during a nationally declared public health emergency due to respiratory transmitted infectious disease.

This new code is intended to capture the following practice expense activities:

  • Time over what is included in the primary service of clinical staff time (registered nurse [RN]/ licensed practical nurse [LPN]/ medical technical assistant [MTA]) to conduct a pre-visit phone call to screen the patient (symptom check), provide instructions on social distancing during the visit, check patients for symptoms upon arrival, apply and remove PPE, and perform additional cleaning of the examination/procedure/imaging rooms, equipment, and supplies
  • Three surgical masks
  • Cleaning supplies, including additional quantities of hand sanitizer and disinfecting wipes, sprays, and cleansers

The code should only be reported when the service is rendered in a non-facility place of service (POS) setting, such as a physician office, and in an area where the activities are required to lessen the transmission of the respiratory disease. The code should be reported only during a PHE due to a respiratory disease and only for additional items required to provide a safe in-person service. The code is to be reported once per in-person patient encounter regardless of the number of services provided at that encounter.

Currently, there are no relative value units (RVU) assigned to the code. The AMA has sent a request to the Centers for Medicare and Medicaid Services (CMS) to immediately implement the code and to assign practice expense RVUs based on input provided by the AMA. Practices can choose to assign a charge and submit the code to third-party payers however individual payer policies will dictate how the claim will be processed.

A special edition CPT Assistant article addressing this code and an additional COVID related laboratory code can be accessed here

Advocacy Update from AAPM President Ajay Wasan, MD MSc

Today AAPM President Ajay D. Wasan, MD MSc issued the following message to members about the CMS Proposed ’21 Medicare Physician Fee Schedule and its impact on pain medicine specialists.

Dear Colleagues, 

I am writing today to inform you about one of AAPM’s recent advocacy efforts regarding payment policies and rates for pain medicine specialists. On August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2021. While the proposed rule predicts an almost 11% overall reduction in payments, the impact will not affect all physicians and specialties in the same manner. In fact, Pain Management specialists may realize a 7% increase overall in Medicare payments.

As you may know, the Social Security Act, that established Medicare, requires that increases or decreases in relative value units (RVUs) may not cause the amount of expenditures for the year to differ by more than $20 million from what it would have been in the absence of any changes. If the threshold is exceeded, adjustments are made to the dollar conversion factor (CF) to maintain budget neutrality.

For 2021, the primary reason for the adjustments is due to significant increases in the RVUs for the revised Office/Outpatient Evaluation and Management (E/M) services (99202-99215). The proposed rule confirms CMS’s intention to implement these new codes and finalize guidelines and payment rates. The increases are based on recommendations on resource costs from the AMA/Specialty Society RVS Update Committee (RUC), which AAPM participates in and advocates on behalf of its members. Since office/outpatient E/M services account for approximately 20% of overall expenditures, an increase in the value for these codes makes a substantial impact on the fee schedule. As a result, the proposed rule estimates a conversion factor (CF) of $32.26 which is a $3.83 reduction from the 2020 CF of $36.09.

Impact on Pain Physicians
Pain specialists who provide multimodal care, including a mix of initial and follow up evaluations in addition to the procedures they perform, are likely to see greater reimbursement for the E/M visits and greater overall practice revenue. Nevertheless, despite CMS’ goal of reducing reimbursements for procedures, the AAPM representatives working with RUC will continue to fight for appropriate procedure reimbursement and challenge any and all attempts to reduce these payments in our specialty.

For some time, CMS policies and reimbursement decisions have effectively shifted reimbursement from procedures toward more comprehensive care-based services such as E/M services. This is reflected in the current plan to not apply the E/M increases to those E/M services included in surgical procedures with a 10 and 90-day global period. In other words, pain specialists who practice multimodal care and integrate the use of procedures, medications, physical therapy, and other modalities are likely to see an increase in practice revenue from their E/M services. These changes will encourage physicians to review treatment plans, establish long term goals, and focus more on patient engagement.

The current trend by pain medicine specialists to offer multimodal services with an appropriate mix of E/M services not only improves patient care, it also supports the financial health of physician practices.

Budget Neutrality and the Public Health Emergency
The AMA and many specialty societies had proposed to CMS that the budget neutrality adjustment should be waived considering the COVID-19 public health emergency. While the proposed rule did not accept that recommendation, we encourage you to submit comments. The comment period is open until October 5, 2020.

AAPM leadership and staff will continue to review possible actions in collaboration with the AMA and other specialties societies to reduce the financial hardship on physicians imposed by the negative change to the dollar conversion factor.

You can find more details on the AAPM website regarding this advocacy effort. AAPM leadership and staff will continue to review possible actions in collaboration with the AMA and other specialties societies to reduce the financial hardship on physicians imposed by the negative change to the dollar conversion factor.

Thank you for your dedication to pain medicine. We stand with you and your patients and will continue to work to influence legislators, payors, and others in position to set policies.

Ajay D. Wasan, MD MSc
President AAPM

CMS Releases Proposed Rule for 2021 Physician Fee Schedule

On August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2021. While the proposed rule predicts an almost 11% overall reduction in payments, the impact will not affect all physicians and specialties in the same manner. In fact, pain management specialists may realize a 7% increase overall in Medicare payments.

The Basis for the Change in Payment

The Social Security Act, that established Medicare, requires that increases or decreases in relative value units (RVUs) may not cause the amount of expenditures for the year to differ by more than $20 million from what it would have been in the absence of any changes. If the threshold is exceeded, adjustments are made to the dollar conversion factor (CF) to maintain budget neutrality.

For 2021, the primary reason for the adjustments is due to significant increases in the RVUs for the revised Office/Outpatient Evaluation and Management (E/M) services (99202-99215). The proposed rule confirms CMS’s intention to implement these new codes and finalize guidelines and payment rates. The increases are based on recommendations on resource costs from the AMA/Specialty Society RVS Update Committee (RUC), which AAPM participates in and advocates on behalf of its members. Since office/outpatient E/M services account for ~20% of overall expenditures, an increase in the value for these codes makes a substantial impact on the fee schedule. As a result, the proposed rule estimates a conversion factor (CF) of $32.26 which is a $3.83 reduction from the 2020 CF of $36.09.

As a result, pain specialists who provide multimodal care, including a mix of initial and follow up evaluations in addition to the procedures they perform, are likely to see greater reimbursement for the E/M visits and greater overall practice revenue. Nevertheless, despite CMS’ goal of reducing reimbursements for procedures, the AAPM representatives working with RUC will continue to fight for appropriate procedure reimbursement and challenge any and all attempts to reduce these payments in our specialty. 

Impact on Physicians and Specialties

The payment impacts in the proposed rule reflect averages by specialty based on Medicare utilization and classifications. Specialties with a greater proportion of E/M services may see increases in payments while those specialties that are primarily procedural-based may see decreases.

AAPM President Ajay D. Wasan, MD MSc, commented, “For some time, CMS policies and reimbursement decisions have effectively shifted reimbursement from procedures toward more comprehensive care-based services such as E/M services. This is reflected in the current plan to not apply the E/M increases to those E/M services included in surgical procedures with a 10 and 90-day global period. In other words, pain specialists who practice multimodal care and integrate the use of procedures, medications, physical therapy, and other modalities are likely to see an increase in practice revenue from their E/M services. These changes will encourage physicians to review treatment plans, establish long term goals, and focus more on patient engagement.”

Although pain medicine physicians do perform procedures, office visits comprise a significant portion of the typical services offered by comprehensive pain medicine practices. Therefore, the predicted average for pain medicine specialties reflect an increase in Medicare payments. The payment impact for an individual physician could vary from the average and would depend on the mix of services he or she furnishes.

Dr. Wasan continued, “The current trend by pain medicine specialists to offer multimodal services with an appropriate mix of E/M services not only improves patient care, it also supports the financial health of physician practices.”

Budget Neutrality and the Public Health Emergency

The AMA and many specialty societies had proposed to CMS that the budget neutrality adjustment should be waived considering the COVID-19 public health emergency. While the proposed rule did not accept that recommendation, comments on the proposed rule will be accepted until October 5, 2020. In the absence of positive action by CMS, Congress can waive the budget neutrality payment reductions. Historically, Congress has eliminated reductions in physician payments based on the prior formula for neutrality adjustments known as the Sustainable Growth Rate (SGR).

AAPM leadership and staff will continue to review possible actions in collaboration with the AMA and other specialties societies to reduce the financial hardship on physicians imposed by the negative change to the dollar conversion factor.

View text of the proposed rule

Access the CMS fact sheet to learn more. 

CMS Issues Summary of Physician Fee Schedule Policies During the Public Health Emergency (PHE)

The Centers for Medicare and Medicaid Services (CMS) has issued a Medicare Learning Network (MLN) article with an effective date of June 12, 2020. The article summarizes the policy changes impacting the Physician Fee Schedule during the time of this Public Health Emergency (PHE). During the early part of the PHE, numerous changes were made to reimbursement policies associated with telehealth and non-face-to-face services. The article addresses the cumulative changes that occurred over this period. Specifically, the following topics are addressed:

  • Expansion of telehealth services to include certain hospital-based services
  • Outlines the change in requirements for telehealth modalities
  • Expansion of virtual check-in services to new and established patients
  • Direct supervision requirements for services provided by clinical staff
  • Reimbursement of telephone services and expansion of codes to both new and established patients
  • Documentation, code selection and reimbursement of E/M services during the PHE
  • Changes to supervision requirements for diagnostic tests
  • Application of Teaching Physician requirements for residents and expansion of therapy services provided by students
  • Flexibilities for Opioid Treatment Programs to use interactive technology for counseling, therapy and assessments
  • Guidelines for ordering COVID-19 testing

​ The article can be accessed here.

Message from the AAPM President about COVID-19

​AAPM has been monitoring CDC guidance related to COVID-19. Today AAPM President Ajay D. Wasan, MD MSc issued the following message to members.

Dear Colleagues:

By now I am sure that you have received many lengthy COVID emails and so I will get to the point. AAPM has been monitoring CDC guidance related to COVID-19, and we offer the following thoughts to our members:

The CDC suggests delaying and not having patients come into the office for elective medical care. Certainly, it is a difficult issue to determine to what extent pain care is ‘elective’ vs. medically necessary, and the consideration for limiting outpatient pain care also depends on the extent of COVID-19 and the risk of acquiring it in your area.

At the very least it seems prudent to reschedule elective procedures/injections, initial evaluations, and follow-up visits in those patients at a high risk of complications from COVID-19. These subgroups include those 65 years old or older, those with important medical comorbidities (such as cardiac disease, pulmonary disease, or diabetes), the immunocompromised, and patients coming from nursing homes or long-term care facilities.

The CDC and the Trump administration have encouraged telemedicine visits in place of in-person follow up visits for elective medical care. The DEA has confirmed that it is reasonable in this crisis to renew controlled substance prescriptions after a telemedicine evaluation or telephone discussion with the patient when appropriate and if consistent with state law (such as by electronic prescribing to avoid a high risk patient coming in for a routine opioid follow up visit).

CMS has also relaxed the requirements for using telemedicine codes for billing and they have pledged to pay for these codes equivalent to in person visits. There are weblinks below that explain further how to use these codes effectively in your practice.

We are all struggling to adjust—both professionally and personally. In the coming weeks, our American Academy of Pain Medicine (AAPM) will work to keep us abreast of developments that are specific to our practice areas. Initially, we are providing updated billing and coding guidance that are consistent with the latest messaging coming from CMS regarding the expanded use of telemedicine codes. These insights were prepared under the guidance of the AAPM’s Coding and Reimbursement Committee, which represents our specialty at the CPT and RUC, and regularly provides information to AAPM members in the bi-monthly AAPM e-Newsletter.

Our AAPM will continue to monitor developments that are particular to pain medicine. Thank you for your continuing efforts on behalf of our patients.

Ajay D. Wasan, MD MSc
President AAPM

CMS Approves First State Request for 1135 Medicaid Waiver in Florida

The state’s approval letter can be found here, and includes flexibilities that enable the state to waive prior authorization requirements to remove barriers to needed services, streamline provider enrollment processes to ensure access to care for beneficiaries, allow care to be provided in alternative settings in the event a facility is evacuated to an unlicensed facility, suspend certain nursing home screening requirements to provide necessary administrative relief, and extend deadlines for appeals and state fair hearing requests. These flexibilities will enable the state to focus its resources on combatting this outbreak and provide the best possible care to Medicaid beneficiaries in their state. 

Full story.

President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak

The Trump Administration today announced expanded Medicare telehealth coverage that will enable beneficiaries to receive a wider range of healthcare services from their doctors without having to travel to a healthcare facility. Beginning on March 6, 2020, Medicare—administered by the Centers for Medicare & Medicaid Services (CMS)—will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country.

Full story.

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