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What’s Changed as a Result of CMS Final Rule 2019

National Government Services Summary of Highlights

CMS 2019 Final Rule Changes NGS Provider Points and Reminders
1. E/M Change: Home Health Visits

CMS has removed the requirement for providers to document the medical necessity of furnishing a home visit rather than an office visit.
  • Effective 1/1/2019, providers no longer need to document the medical necessity of performing an E/M visit in the home rather than in the office setting.
  • CPT Codes impacted: 99341‒99350.
2. E/M Changes: Guidelines to Follow/When to Expect Changes

CMS Final Rule excerpt:
“For CY 2019 and 2020, we will continue the current coding and payment structure for E/M office/outpatient visits, and, therefore, practitioners should continue to use either the 1995 or 1997 versions of the E/M guidelines to document E/M office/outpatient visits billed to Medicare for 2019 and 2020 (with the exception of our final policy to eliminate redundant data recording).”
  • For CY 2019–2020, the current coding and payment structure for E/M office/outpatient visits remains unchanged.
  • CPT Codes impacted: 99201‒99205, 99211–99215.
  • When performing, documenting and billing for these services, providers should continue to follow the CMS 1995 and 1997 E/M guidelines, except for specific changes described below in this document.
  • Beginning in CY 2021, CMS plans to consolidate payment rates for E/M levels 2–4 and to implement additional time and specialty codes for E/M services, in addition to modifying documentation expectations. Additional educational information will be available as we approach CY 2021.
3. E/M Change: Use of Previous Documentation in a Medical Record

CMS Final Rule excerpt:
“We are finalizing our proposal that, effective January 1, 2019, for new and established patients for E/M office/outpatient visits, practitioners need not reenter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information. We note that this policy to simplify and reduce redundancy in documentation is optional for practitioners, and they may choose to continue the current process of entering, reentering and bringing forward information (83 FR 35838). The option to continue current documentation processes may be particularly important for practitioners who lack time to adjust workflows, templates and other aspects of their work by January 1, 2019.”
  • As of 1/1/2019, for new and established E/M patient visits in the office and outpatient setting, providers may refer to previously documented information on the patient’s chief complaint and history, which may have been entered in the medical record by ancillary staff or by the patient.
  • This guideline also applies to documentation for new and established CPT ophthalmology services (92002/92004 and 92012/92014).
  • In a teaching hospital setting, this concept may apply to documentation entered by residents or medical students in both the outpatient and inpatient settings; please see below.
  • CPT codes impacted by this change in the office and outpatient setting: 99201–99205, 99211–99215.
  • CPT codes impacted in the teaching hospital setting include the outpatient codes above and also inpatient codes 99221–99223, 99231–99233.
  • Providers may continue to elicit this information independently, without support of ancillary staff or the patient.
  • Of note: there is a clear expectation that complaint and history information, particularly HPI, be carefully reviewed and noted by the performing provider. In many circumstances, clinical skill is needed to determine the scope and course of questioning relative to this process; the provider remains obligated to assess previously recorded information and to expand upon it as medically necessary.
  • Previously recorded information on defined E/M elements (history, examination and medical decision making) may also be referred to in documentation for a visit, when there is clear evidence that the provider has reviewed this earlier information and either updated it as appropriate to the clinical scenario.
  • An example of this last point: “12/15/2018: Since last seen on 11/10/2018, no significant interval history. Physical examination remains unchanged except for drop in BP from 160/90 to 140/80 today on current Losartan regime. Will maintain all current meds and schedule return visit in early February 2019.” As referenced in the 2nd bullet, the concept of reviewing prior entries made by members of a medical team in a teaching hospital, including house staff and students, and modifying as necessary (but not repeating the prior info) is acceptable in both the office and hospital environment.
4. E/M Change: Internet Consultations

Codes For the Consulting Provider: Interprofessional Internet Consultation

99446:
Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5–10 minutes of medical consultative discussion and review.

99447:
Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11–20 minutes of medical consultative discussion and review.

99448:
Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 21–30 minutes of medical consultative discussion and review.

99449:
Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review.

99451
: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified healthcare professional, five or more minutes of medical consultative time.

Code For the Requesting Provider:

99452
: Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified healthcare professional, 30 minutes.
99446, 99447, 99448, 99449, 99451:
  • Payable only to providers who are permitted to bill E/M services.
  • Interprofessional Internet consultation service represents a request by the attending/primary physician to a specialist physician, requesting an expert opinion, and the response by the consulting physician.
  • Service is not applicable for consultative communication between same specialty physicians (denied as concurrent care). CPT codes 99446, 99447, 99448, 99449 and 99451 are for use by the consulting physician who is providing an opinion, as requested, based on information obtained via telelphone, Internet or electronic health record(s).
  • Codes do not include any element of F2F service to the patient—these are “provider-to-provider” services.
  • Internet consultation is not billable for any service that requires face-to-face physical examination (e.g., medically necessary preoperative clearance); when physical examination is a service component, these codes are not payable based on quality of care and medico-legal requirements.
  • Not payable on the same DOS as F2F E/M services (i.e., 99201–99205, 99211–99215, 99221–99223, 99231–99233).
  • May be reported before a transfer of care has been accepted by the consulting provider; may not be reported within 14 days after the transfer of care is effectual.
  • May be reported by the consultant for patients who are either new or established, when the established patient has a new problem or exacerbation of a previously known problem.
  • Codes are not reportable if the consultant has performed a F2F encounter with the patient in the prior 14 days.
  • If more than one telephone/Internet contact is needed to complete the consult, service should be reported using only one code, reflecting the cumulative time spent.

99446, 99447, 99448, 99449:

  • Codes are not reportable when the purpose of a telephone/Internet communication is to arrange a transfer of care or other F2F service.
  • Time-based codes which include both a verbal and written report to the requesting provider
  • Require time documentation.

99451:

  • Time-based code, requiring five or more minutes of consultative time.
  • Time includes only a written report to the requesting provider.
  • Requires time documentation.

99452:

  • For use by the original treating provider who is requesting the consultation.
  • Requires documentation of at least 15 minutes of time spent in discussion and information-sharing with the consulting provider.
  • If time spent on this service exceeds 30 minutes, and meets criteria for non-F2F prolonged service, CPTs 99358–99359 may be added to the claims as appropriate to time spent.
  • Patient’s verbal consent must be documented in the record for each service; cost-sharing applies.
  • Payable only to providers who are permitted to bill E/M services.
  • Requesting provider maintains documentation of initial contact and discussion with consultant.
  • Consulting/billing provider maintains documentation of requesting provider, topic and summary of recommendation.
5. Virtual Check-In (HCPCS G2012)

HCPCS Definition:
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion.
  • Providers utilizing this code are limited to those who can bill E/M (physicians/ NP/PAs).
  • Telephone calls completed by clinical office staff do not qualify for use of this code.
  • May be used for established patients only; does not apply to new patient services.
  • Service can bear no relation to an E/M service within the prior seven days.
  • Service cannot result in an E/M service within the ensuing 24 hours (or soonest appointment).
  • 5–10 minutes of medical discussion required.
  • Real-time, two-way audio only (telephone); may be enhances with video or other data transmission (excludes voice messages- must be a live conversation).
  • Requires beneficiary’s verbal consent for each service; cost-sharing applies.
  • No frequency limitation; CMS will monitor frequency to determine whether a limit is necessary
  • Documentation: Provider documents patient’s consent, date, time, duration of service along with brief summary of topic(s) discussed.
6. Remote Evaluation of Prerecorded Patient Information (HCPCS Code G2010)

Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment).
  • Distinctly separate service from G2012.
  • May be used only for established patients.
  • Includes receipt and interpretation of images within 24 business hours.
  • Cannot be related to an E/M service within the prior seven days by the same provider (bundled).
  • Service cannot result in an E/M service within the ensuing 24 hours (or soonest appointment).
  • Cannot result in a subsequent office visit with the interpreting provider (bundled).
  • Follow-up may take place via phone call, audio/video communication, secure text messaging, email, or patient portal communication. Such communication must be compliant with HIPAA and other relevant laws.
  • When the quality of the prerecorded information is insufficient to allow the clinician to assess the need for medical treatment, the service may not be billed; in these situations, other methods for obtaining sufficient images should be used or other suggested appropriate alternatives. The provider may ask the patient to send photos or videos with a higher degree of resolution, or may request that the patient arrange for an office visit.
  • This service is not considered a Medicare telehealth service and is not subject to telehealth restrictions, including geographic restrictions.
  • Requires verbal or written/electronic beneficiary consent for each billed service; cost-sharing applies.
  • No frequency limitations; CMS will monitor utilization.
  • Documentation: Provider documents patient’s consent, review and interpretation of images and also date and time of beneficiary contact and content discussion.
7. Telehealth Change: HCPCS G0513 and G0514
  • HCPCS code G0513 (Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service).
  • HCPCS code G0514 (Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition).
  • Applies to preventive services performed only in the office or outpatient setting.
  • Requires 30 or more minutes of direct patient contact beyond the usual service time of the preventive service.
  • Provider must spend at least 15 minutes of time to fulfill the definition of G0513.
  • G0514 may not be added until the provider has completed the full 30 minute expectation of G0513 and spent an additional 15 minutes of time into the next half hour.
  • Refer to CMS Medicare Preventive Services chart for services designated with "clock" indicator:
  • Prolonged time must be medically necessary as supported by the patient’s condition, limitations or other time-related factor (e.g., need for a translator).
  • Documentation: Provider documents the extra time as duration (“30 minutes”) or clock time (“1:00–1:30 p.m.”) and the factor(s) supporting the need for extra time.
8. Telehealth Change: Home Dialysis

CMS:
CMS is finalizing the addition of renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites, and to not apply originating site geographic requirements for hospital-based or critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes, for purposes of furnishing the home dialysis monthly ESRD-related clinical assessments.
  • This changes applies only to physicians, providers and suppliers who are participating in the CEC and providing telehealth services to Medicare ESRD beneficiaries associated with the CEC model. Reference CMS MLN MM10314 and MM11043).
  • Providers are reminded that this service is only applicable for patients who receive a face-to-face visit, without the use of telehealth, at least monthly during the initial three months of home dialysis and at least once every three consecutive months after the initial three-month period.
  • Approved telehealth originating sites have been expanded for the purpose of monthly ESRD-related clinical assessments via telehealth technology to now include:
    • Renal dialysis facilities
    • Home (for home-dialysis patients)
  • No originating site facility fee is applicable when originating site is patient’s home.
  • Geographic requirements no longer apply to originating site renal dialysis centers that are based in:
    • hospitals (including critical access hospitals)
    • renal dialysis facilities
    • patients’ homes, for patients receiving home dialysis
      • When the patient is located at a hospital (including CAC), a renal dialysis facility or at the patient's home, this service may be performed in any location
9. Telehealth Change: Diabetes Self-Management Training (DSMT)

CMS:
CMS is clarifying DSMT policy to specify that all ten hours of the initial DSMT training and the two hours of annual follow-up DSMT training may be furnished via telehealth in cases when injection training is not applicable.
  • When injection training is not applicable, all ten hours of initial DMST training and subsequent annual two-hour training may be furnished via telehealth.
  • Use appropriate distant site POS code as described above.
  • Use appropriate originating facility fee code as described above.
  • Can only be furnished by a physician. PA, NP, CNS, CNM, clinical psychologist, clinical social worker, registered dietician or nutrition professional.
10. Telehealth Change: Modifier G0

CMS: Effective for claims with dates of service on and after 1/1/2019, MACs will accept new informational HCPCS modifier G0 to be used to identify telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
  • Modifier G0 (G zero) is an informational modifier) to identify acute stroke telehealth services.
  • Geographic HPSA restrictions for approved originating sites (now including mobile stroke units) have been removed; the beneficiary may receive this service at an approved originating site, regardless of the geographic location of the approved originating site.
  • Modifier G0 may be used on all Medicare approved telehealth services performed for stroke evaluation; CMS has not established a list of restricted services.
  • Modifier to be added by telehealth provider and by originating site to identify acute stroke care.
  • Permissible originating sites for acute stroke telehealth services:
    • Currently eligible telehealth originating sites
    • Mobile stroke units (POS 15) have been added as approved orginating sites
    • Telehealth distant site codes billed with POS code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X or 098X) or
    • Telehealth originating site facility fee, billed with HCPCS code Q3014.
  • Valid for telehealth distant site codes billed with POS 02.
  • Valid for CAH Method ll, revenue codes 096X, 097X or 098X.
  • Valid for telehealth originating site facility fee, billed with HCPCS Q3014.
  • Of note: Originating sites that remain excluded from this service: renal dialysis facilities (POS 65) and patient’s home POS 2).

Revised 2/13/2019
Posted 1/15/2019


Last Modified: 2/14/19
What’s Changed as a Result of CMS Final Rule 2019
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