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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. 

Virtual Services During the Time of COVID-19

Public and private insurers have taken steps to increase telehealth services during the public health emergency due to COVID-19. CMS is expanding its Virtual Services benefits on a temporary and emergency basis. The expanded benefit is retroactive to March 1, 2020 and allows patients to receive care at their place of residence rather than in a physician office or a hospital. The most recent expansion included payment for telephone calls with patients.

Part of the expanded benefits include allowing telehealth services to be reported by a variety of non-public facing technologies. The requirement for synchronous audio/visual requirements remains. Services can be reported for both new and established patients and should be reported using the same code (i.e. 99201-99215) that would have been reported if the patient was seen for an in-person visit. Reimbursement will be the same as if the patient was seen in the office or other appropriate setting. Levels of service for office visit codes can be based on either time or medical decision-making. It is not necessary to meet the documentation requirements related to the key components (history, exam, medical decision-making) when selecting a level of service.

Based on input from the medical community, CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020. The codes for telephone services (99441-99443) are time-based services and have restrictions on reporting when they are provided in conjunction with other patient encounters. It is important to read the CPT instructions for reporting telephone services to understand the requirements and limitations associated with these codes.

AAPM offered a webinar “Coding Services in the Wake of COVID-19” on April 15 that addresses the appropriate coding and reporting of telehealth services and other virtual services covered by Medicare. The webinar can be accessed here.

AAPM also convened a panel of pain medicine experts to present a webinar, “Pain Management Best Practices During the COVID-19 Pandemic and Public Health Crises: A Discussion of the New Guidelines.” This webinar is also available and can be viewed here.

Guidelines are changing as payers attempt to revise policies and adjust their systems to meet policy changes. You should visit your Medicare, Medicaid and private payers’ websites and/or read all payer communications to determine coverage and specific instructions. 

Incorrect Billing of HCPCS L8679 – Implantable Neurostimulator

CMS has issued a MLN (Medicare Learning Network) article concerning the inappropriate reporting of HCPCS supply code L8679 (Implantable neurostimulator, pulse generator, any type) for electro-acupuncture devices. These devices are applied behind the ear using an adhesive and/or with needles inserted into the patient’s ear and do not require surgical implantation.  

Code L8679 should only be reported with procedures that require surgical implantation into the central nervous system or targeted peripheral nerve. These procedures are usually performed in an operating room. The MLN article (number SE2001) provides a list of appropriate procedures that must accompany any claims that include code L8679. It can be accessed here.

As of March 1, 2020, claims billed with HCPCS L8679 must be billed with the same date of service as the applicable surgical procedure code. Claims for code L8679 reported with an appropriate surgical code will be suspended for medical review to verify that coverage, coding, and billing rules have been met. Claims submitted without an appropriate procedure code will be rejected.

Please make sure your coding and billing staff are aware of the correct use of code L8679 and the changes in the CMS policy. The National Coverage Determination Manual Section 160.7 on implanted peripheral nerve stimulators is available here.

CMS Issues Final Rule for Physician Fee Schedule for 2020

The Centers for Medicare & Medicaid Services (CMS) issued its Final Rule for 2020 that that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS). As proposed, the 2020 PFS conversion factor is $36.09 which is $0.05 above the 2019 conversion factor. The conversion factor is multiplied by the total adjusted Relative Value Units (RVUs) to achieve a payment amount for the services included in the Medicare Physician Fee Schedule.

 The Final Rule also addresses public comments submitted in response to the Proposed Rule released in July. AAPM provided written comments to several areas of importance to Pain Medicine physicians that were outlined in the September 25 AAPM E-News.

AAPM specifically addressed the practice expense inputs for the new genicular injection and RFA codes (codes 64624 and 64454). CMS had proposed a decrease in the AMA/Specialty Society Relative Value Update Committee (RUC) recommended practice expense inputs for these services. The Proposed Rule included only one cannula and one RF kit for code 64624. After consideration of comments submitted by AAPM and others, CMS agreed to increase the number of cannula and kits from one to three. This change also resulted in acceptance of the RUC recommended equipment time which was also decreased in the Proposed Rule. AAPM also opposed the CMS change to the recommended work RVUs (wRVU) for the RFA code. Unfortunately, CMS did not accept the submitted comments, therefore the wRVU for code 64624 (Destruction by neurolytic agent genicular nerve branches including imaging guidance, when performed) will be 2.50 rather than 2.62 as recommended by the RUC.

Similarly, CMS proposed decreases in the practice expense inputs for the new codes for sacroiliac injection and RFA (codes 64451 and 646250. The Final Rule considered the AAPM submitted comments and increased the number of spinal needles included in the PE from 3 to 4 and accepted the RUC recommended equipment time for these services.

AAPM and other societies responded to the CMS proposal to decrease the RUC recommended wRVUs for many of codes in the revised family of somatic nerve injections. Despite the comments and rationales provided by several societies, CMS is maintaining the wRVUs as outlined in the July Proposed Rule.

Of other interest, CMS confirmed its plan to align its E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits. Further, it accepted the RUC recommended work values for these services. These changes will not be incorporated until 2021.

CMS is also finalizing broad modifications to its documentation policy so that physicians, physician assistants, and advanced practice registered nurses can review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, physician assistants, and APRN students, nurses, or other members of the medical team.

AAPM is hosting a webinar that will review these areas and other important payment policies that impact Pain Medicine practices, as well as a review of the CPT and ICD-10 changes for 2020. The webinar “Preparing for 2020: Update on Coding and CMS Policy Changes” will be held on December 11 at 2-3PM CT. Registration information can be found here.

The CMS fact sheet on the Final Rule can be accessed here. The complete Final Rule can be accessed here.

2018 Pain Management Codes Posted on Website

Source: Emily Hill, PA, AAPM Coding Consultant
Date: January 10, 2018

The Coding and Reimbursement Committee has updated the coding information available on the AAPM website. New charts have been posted that include information concerning Medicare’s 2018 Relative Value Units (RVUs) for codes commonly reported by Pain Medicine Physicians. The title page provides links to CMS web pages that provide additional information and outlines the basis for the 2018 reimbursement rates.

The charts are organized according to the type of service (e.g. E/M, injections, radiology) with new and revised codes highlighted. As appropriate, some charts contain information indicating which codes include imaging guidance as well as which codes can be reported with the bilateral modifier. There is also a separate chart that lists all the new and revised codes for 2018. There were no significant changes impacting Pain Medicine Physicians.

The Relative Value Units in the charts reflect the combined RVUs for physician work, practice expense and professional liability (total RVUs). RVUs in the “facility” column are used to calculate payments in the hospital or other facility setting. RVUs in the “non-facility” column are used for services provided in a physician office.

View the charts of Common Pain Medicine Codes (login required)…

Bilateral Surgery and Medically Unlikely Edits

Source: Emily Hill, PA, AAPM Coding Consultant
Date: January 24, 2018

CMS has released a revised article that addresses the appropriate reporting of bilateral procedures and the potential impact of its rules known as “medically unlikely edits” (MUE) on reimbursement. The revised article provides more examples and details.

Bilateral procedures are those that are performed on paired organs or body structures. The use of the bilateral modifier 50 depends on the code descriptor and the bilateral “indicator” assigned by CMS. These indicators determine if reimbursement will be adjusted and paid at 150% of the Physician Fee Schedule (PFS) rate for the code. A bilateral payment indicator of 1 results in a payment adjustment. Codes assigned an indicator of 0, 2, or 3 will not result in a bilateral payment adjustment. When appropriate to append modifier 50, Medicare instructs that the CPT code be reported with modifier 50 as a single line on the claim and with 1 unit of service.

A MUE is the maximum number of units that can be reported for a particular CPT code by the same provider for the same patient on the same date of service. The MUEs are based on claims history and input from specialty societies on common clinical practice. MUEs may limit the number of units that can be reported with certain CPT codes. The reporting of bilateral procedures on more than one claim line or with more than one unit of service may exceed the number of allowed units and result in denials. It is therefore important to follow Medicare’s instructions when reporting bilateral procedures.

The bilateral indicators for CPT codes can be found in the PFS Relative Value Files.

The recently revised AAPM coding and reimbursement tool, Common Pain Medicine Codes (login required), also denotes which codes allow modifier 50.

Targeted Probe and Education (TPE)-New CMS Initiative

Source: Emily Hill, PA, AAPM Coding Consultant
Date: February 7, 2018

In October 2017 CMS launched a nationwide program to better target medical review, limit the number of medical records requested, and put an emphasis on education and assistance in correcting claims errors. The goal is to help identified providers and practices by having Medicare Administrative Contractors (MACs) work in person with the practice to identify specific errors and help correct them quickly.

Most providers will never need TPE. The program focuses on providers who have unusual billing patterns or billing practices that vary greatly from their peers. Practices will receive a letter if chosen for the program and CMS will request 20-40 claims with the accompanying documentation. If found compliant, then you will not be reviewed for at least one year on the identified topic. If denials are identified, you will be invited to a one-on-one education session and have 45 days to make changes and improve. The session will likely be held via teleconference or webinar and the provider will have the opportunity to ask questions about their specific claims as well as the underlying CMS policy.

View information on TPE. The page includes links to TPE Q&A documents as well as a one-page information sheet.

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