Key updates in 2022 may affect documentation, coding, billing and reimbursement for many practices. This year, rheumatology practices should prepare for important revisions with regard to evaluation and management (E/M) and split/shared billing policies, as well as new guidelines and policies for telehealth services.
Medicare Physician Fee Schedule Changes
The Centers for Medicare & Medicaid Services (CMS) was set to lower the 2022 conversion factor (i.e., the amount Medicare pays per relative value unit [RVU]) from $34.89 to $33.59, but in response to advocacy from the ACR and other provider and patient groups, Congress intervened in December with a one-year rate increase of 3%. The 2022 conversion factor is now $34.6062, nearly the same as in 2021.
Office & Other Outpatient E/M Services
In 2021, the Current Procedural Terminology (CPT) code set made substantial changes to the new and established patient E/M codes (99202–99215). For 2022, the CPT has clarified several aspects of those changes, including:
- Defining specific activities that don’t count when time is used to determine the level of service: Travel, teaching that is general and not limited to management of a specific patient, and time spent on other, separately reported services.
- Clarifying when to report a test that is considered but not selected after shared decision making: A test that is considered but not performed counts if the consideration is documented in the patient’s medical record. For example, the physician may explain to the patient that a diagnostic test the patient requested would have little benefit.
- Defining “analyzed” for reporting tests in the data column: “Analyzed” means using data as part of the medical decision-making (MDM) process. Tests that don’t require an analysis still count if they are a factor in diagnosis, evaluation or treatment.
- Clarifying the definition of a “unique” test: Multiple results of the same tests during an E/M service are considered one unique test. Tests with overlapping elements are not considered unique even if they have distinct/separate CPT codes.
- Clarifying what is meant by “discussion” between physicians/other qualified healthcare professionals and patients: “Discussion” requires a direct, interactive exchange. Sending notes does not count.
Principal Care Management Services
The CPT added a new category of principal care management (PCM) codes (99424–99427) to the Care Management Services section. Unlike chronic care management and complex chronic care management, which require at least two chronic conditions, PCM focuses on medical or psychological needs caused by a single, complex chronic condition expected to last at least three months. PCM services include establishing, implementing, revising or monitoring a care plan directed toward that single condition. PCM codes can be reported by different physicians or qualified healthcare professionals in the same calendar month. Clinical documentation should reflect coordination of care among the managing clinicians.
- 99424—Principal care management services, for a single, high-risk disease with the following required elements:
- One complex chronic condition expected to last at least three months that places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline or death;
- The condition requires development, monitoring or revision of the disease-specific care plan;
- The condition requires frequent adjustments in the medication regimen, or the management of the condition is unusually complex due to comorbidities; and
- Ongoing communication and care coordination between relevant clinicians providing care.
- +99425—Each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure).
Codes 99426 and 99427 are for services provided by clinical staff under the direction of a physician or QHP.
- 99426—Principal care management services, for a single high-risk disease with the same required elements as code 99424. First 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
- +99427—Each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (list separately in addition to code for primary procedure).
Note: Use 99425 in conjunction with 99424, and use 99427 in conjunction with 99426. Principal care management services of less than 30 minutes in a calendar month are not reported separately.
Split/Shared Visits
2022 is a transitional year for split/shared visits performed with an E/M service. Currently, E/M services may be billed only as shared or split services when provided in a facility setting. Prior to 2022, they could be provided in an office setting if they also met the requirements for incident-to billing. The CMS no longer allows shared services in an office setting, although incident-to services are still allowed and the billing criteria should be followed for established patients.
Telehealth Modifiers
Beginning Jan. 1, Anthem and UnitedHealthcare (UHC) aligned their billing requirements for commercial and Medicare Advantage plans to use the new place-of-service (POS) code 10 for telehealth provided in the patient’s home. POS code 02 should continue to be used when telehealth is provided anywhere other than a patient’s home (e.g., a hospital, skilled nursing facility). The modifier code descriptors are defined as:
- POS 02: Telehealth Provided Other Than in Patient’s Home—The location where health services and health-related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health-related services through telecommunication technology.
- POS 10: Telehealth Provided in Patient’s Home—The location where health services and health-related services are provided or received through telecommunication technology. The patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.
Keep in mind, during the COVID-19 public health emergency (PHE), traditional Medicare will continue to require physicians to bill using the POS code they would have used if the service had been provided in person. After the PHE, the CMS will revert to the geographic/originating site requirements for most telehealth services.
Modifier 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System was accepted at the September 2021 CPT Editorial Panel meeting. It is used to describe real-time telemedicine services rendered via audio only.
Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a site distant from that provider. The totality of the information exchanged between the physician or other qualified healthcare professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
It is important to note that further CPT Editorial Panel or Executive Committee actions may affect these codes and/or descriptors. For this reason, code numbers and/or descriptor language in the CPT code set may differ at the time of publication. For example, modifier 93 went into effect Jan. 1, 2022, but will not be published in the CPT manual until 2023.
No Surprise Billing Act
Congress passed the No Surprises Act, which creates protections for patients by banning surprise medical bills under certain circumstances beginning Jan. 1, 2022. Surprise medical billing, or balance billing, results when patients receive care from out-of-network providers or facilities and the service costs are not fully covered by the patient’s insurance provider. New protections regulate certain provider balance billing and create new pathways for patients to better understand the cost of services.
The ACR advocacy team continues to monitor the impact of the No Surprises Act and will report additional information that will impact rheumatology practices. More information is also available from the AMA in a physician toolkit related to the act’s implementation.
The ACR practice management department is working to provide the appropriate training for rheumatologists and their staff to be ready for upcoming changes. The first coding and billing training for 2022 will take place virtually during the ACR Education Exchange on April 29. For questions or information on training, contact the ACR practice management department at [email protected].
