Looming medical billing and coding changes in healthcare policy

A change in government payment policy for dermatologists and other physicians in selecting office coding and billing for evaluation and management (E/M) is scheduled to begin January 2021.

“The Centers for Medicare & Medicaid Services (CMS) decided over a year ago that it wanted a decrease in the documentation burden on the physician,” said Mark Kaufmann, M.D., an associate clinical professor of dermatology at Icahn School of Medicine at Mount Sinai in New York. “CMS proposed creating a new coding system with fewer codes, thereby creating less of a differential and less work that would need to be done by the physician to choose a code when it came to judging a patient’s office visit and the way they would bill that visit.”

CMS provided a timeline to institute the change, in order to allow the American Medical Association (AMA), the Current Procedural Terminology (CPT) code and the AMA’s Relative Value Scale Update Committee (RUC) to come up with an alternative plan. This past July, CMS proposed to institute this alternative plan.

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“The codes remain the same, except for the deletion of one of the E/M codes, but the way that we choose the codes has changed,” says Dr. Kaufmann, who spoke on pending healthcare policy changes relevant to the practicing dermatologist in August at the annual meeting of the Pacific Dermatologic Association in San Diego. “The change in coding will require a re-education of all clinicians in the country over the next 12 months. However, I believe this change in the paradigm for the way we code office visits will be a net positive for the specialty.”

Dr. Kaufmann expects the coding changes to be finalized in November; yet they will likely not take effect until January 2021.

The new coding will be predicated on either time or medical decision making (MDM). “Currently, everyone counts the number of bullet points in their notes that are related to patient history and physical examination,” Dr. Kaufmann said. “Those bullet points will no longer be necessary for billing purposes, although some may be required for good medical care and for medical liability reasons.”

Dr. Kaufmann expects that most dermatologists will use MDM rather than time as their code determinant.

Modifier 25 is a second potential hurdle for the field of dermatology. “This is a billing situation when we do a procedure on the same day as an office visit,” Dr. Kaufmann says. “Presently, we actually have to identify the office visit with the 25 modifier as being separate from the procedure, in order to be paid for both.

CMS has decided not to finalize changes in reimbursement for Modifier 25 visits, for the time being, in response to strong pushback from medical advocacy groups. But CMS has not ruled out potential changes in the future.

In addition, several commercial payers have already instituted a decrease in reimbursement for Modifier 25 visits, according to Dr. Kaufmann.

Global period codes are a third challenge faced by dermatologists. “For instance, packaged into the payment for destroying a wart on a patient’s arm is an office visit, which is assumed to take place over the next 10 days,” Dr. Kaufmann said.

Previously, CMS has sought to eliminate the global visits included in the global period codes commonly used by dermatologists. But it was only prevented by an act of Congress. “CMS is currently revisiting this issue,” Dr. Kaufmann says.

There are also efforts by medical advocacy groups to lessen physician regulatory burden imposed by the Medicare Access and CHIP Reauthorization Act (MACRA) and CHIP (Children’s Health Insurance Program) and the Merit-based Incentive Payment System (MIPS), in order to delivery both more efficient care and decrease rates of physician burnout.

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The MIPS program will probably have some changes next year. The minimum MIPS score required to be exempt from the 9% penalty in 2022 will likely be 50% higher than this year, which will make it more difficult to simply “avoid the penalty.”

“The time has arrived for dermatologists to decide if they will be ‘all in’ in the MIPS program or just ‘take the penalty,’” Dr. Kaufmann says.

“Overall, there are a number of challenges in the reimbursement landscape that we face in the field of dermatology,” Dr. Kaufmann says. “None of them are insurmountable, and it is important that people are aware of the issues, as well as the areas that we are advocating for and against.”

Dermatologists should become advocates for these issues, whether on the local, state or national level, according to Dr. Kaufmann.

“CMS’ ultimate goal is to decrease the cost of healthcare in the country by shifting from volume-based to value-based healthcare,” he says. “We all know where we are going to end up, but the road has been a long and winding one. Each detour that goes up leads to unintended consequences, and we need to be prepared for anything that comes our way.”