Category: Health Care

Evaluation and Management Code Changes Coming in 2021 for 99202-99215

  

While it is only the second month of 2020, it is never too early to look to 2021, when the revised Evaluation and Management (E/M) office codes go into effect per the Centers for Medicare and Medicaid Services (CMS) CY 2020 Physician Fee Schedule (PFS) Final Rule. CMS first proposed the updated Medicare E/M codes July 2018 in the CY 2019 PFS proposed rule to address the common perception that the E/M codes were outdated and to achieve administrative simplification. What is changing?

  • Deletion of code 99201
  • Revision of codes 99202-99215P
  • Components for code selection
  • E/M level of service for office or other outpatient services can be based on:
    • Medical Decision Making (MDM); or
    • Time: total time spent with the patient on the date of the encounter, including non-face-to-face services
  • Creation of a shorter 15-minute prolonged service code

Over the next few months ANA will take a deeper dive into these changes and will continue to share further guidance from CMS. These code changes are intended for increased simplicity and flexibility.  They eliminate the need for the clinician to redocument information, therefore reducing burden and “note bloat”. ANA encourages clinicians impacted to take the next eleven months to better understand how to use the updated codes.

With code 99201 deleted; the Office or other Outpatient Services: new patient code starts with 99202. The updated code states: Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and straightforward medical decision making. The components of history and examination are removed from this updated code.

This continues for 99203, 99204, and 99205 but with the increase in MDM to low MDM, moderate MDM, and high MDM respectively. Codes 99211 through 99215 are for established patients following a similar pattern, except that 99211 will still be available in 2021 with an update of the time to spend performing or supervising the services.

The updated modifications to the criteria for MDM remove ambiguous terms and defines previously ambiguous concepts (such as acute or chronic illness with systemic systems). To qualify for a level of MDM, two of three elements for that level of decision making must be met or exceeded. Starting January 1, 2021, the new MDM table looks like:

Number and Complexity of Problems Addressed at the Encounter
Straightforward: self-limited
Low: Stable, uncomplicated, single problem
Moderate: multiple problems or significantly ill
High: very ill
Amount and/or Complexity of Data to be Reviewed and Analyzed Data is divided into three categories: (1) tests, documents, orders, or independent historian(s) – each unique test, order, or document is counted to meet a threshold number; (2) independent interpretation of tests not reported separately; (3) discussion of management or test interpretation with external physician/other Qualified Health Professional/appropriate source (not reported separately)
Risk of Complications and/or Morbidity or Mortality of Patient Management
Includes risks associated with social determinants of health
Straightforward: minimal risk from treatment – including no treatment – or testing. (effectively no risk)
Low: low risk/very low risk of anything bad, minimal consent/discussion Moderate: would typically review with patient/surrogate, obtain consent and monitor, or there are complex social factors in management (ex: prescription drug management, decision regarding minor surgery with identified patient or procedure risk factors, diagnosis or treatment significantly limited by social determinants of health)
High: need to discuss some pretty bad things that could happen for which physician or other qualified health care professional will watch and monitor (ex: drug therapy requiring intensive monitoring for toxicity, decision regarding emergency major surgery, decision regarding hospitalization)

ANA will continue to provide updates and content as clarifications become available. Currently, The American Medical Association has a module to continue in your education on the updated E/M Office Codes and remember that these codes do not go into effect until January 2021.

What are the Biggest Issues to Watch for in State Legislatures in 2020?

  

Many state legislative sessions have or will be launching soon. Although there is no shortage of issues, with 80 percent or 6,000 state legislative seats up for election across 46 states in November, there’s a desire to wrap up sessions and get out to campaign.  As such, agendas may be limited.

Commencement of the 2020 census in April with subsequent congressional/state legislative redistricting to follow in 2021 is prompting one defining theme in state capitals this year – election security and reform.  

In general, state economies are doing well with record low unemployment. However, annual budgets are always important; all but one State’s Constitution (Vermont) necessitates that the budget be balanced. Education and healthcare are almost always a state’s largest budget expenditures, so attention to issues within these two buckets are generally prevalent.  

Keeping the economy strong includes reducing barriers to employment and this has been particularly evident for those occupations requiring licensure. Occupational licensure reform efforts are still ubiquitous, including re-evaluation of select occupations and the continued need for licensure, expedited licensure particularly for military spouses, and a significant growth in health profession interstate compacts.

More than 40 states introduced scope of practice legislation during the 2019 legislative sessions. Fifty-four bills from 30 states were enacted into law related to behavioral health providers, physician assistants, nurse practitioners and oral health providers. More needs to be done to increase access to care by reducing barriers for qualified practitioners. ANA and state nurses’ associations continue to seek full practice authority for all four roles of Advanced Practice Registered Nurses (Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse Midwifes).

Closure of rural hospitals has led to an increased demand for telehealth services. Legislation and regulation are defining what constitutes as telehealth, which varies, as well as who can use technology, under what circumstances, and how payment issues are resolved. More than 30% of rural Americans do not have access to broadband at home, further complicating use of technology for access to services.

As we await the US Supreme Court’s ruling on the Affordable Care Act (ACA), states are still expanding Medicaid, some with the addition of work requirements, and there is an increased interest in block grants.  While Republicans dominate in both state legislative bodies as well as the Executive Branch, it is likely additional states will attempt to advance legislation to ban abortions. Other health related policy carry overs from 2019 include legalizing medicinal and / or recreational cannabis, with much of this having been done through ballot initiative due to reticent policy makers. Almost 900 bills were introduced in 2019 to address pharmaceuticals and their costs and continued efforts to curb the opioid epidemic, generally viewed as a non-partisan issue. Other public health issues expected to draw attention again include immunizations, gun violence prevention, and efforts to curb e-cigarettes / vaping. 

While it’s unclear how much will be accomplished, your engagement remains critical.  If you are a member of one of ANA’s state affiliates, you have access to intel. Many state nurses’ associations have a vehicle to communicate updates and grassroots alerts. Additionally, sign up for your elected official’s newsletter to follow discussions and debates. Email your state senators and representatives with questions and requests. Better yet, set up an appointment to meet when they are at home in the district. And be sure to get out and vote in November.

To follow ANA’s Federal agenda and locate resources, go to www.RNAction.org

Congress Aims to Keep Campaign Promises on Health Care as Courts Continue to Review Administration Policies

  

By: Gregory Craig and Matthew Fitting

Following a midterm election cycle in which voters consistently listed health care as their top issue priority, members of the 116th Congress have wasted no time in proposing, introducing, and debating several measures that would significantly impact the way Americans receive and pay for health coverage.

Health Care Legislation in the U.S. House of Representatives

Most recently, Rep. Frank Pallone, Jr. (D-NJ), the Chairman of the House Energy and Commerce Committee, on March 26, 2019 introduced H.R. 1884 – the “Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019”. This legislation would strengthen many of the consumer protections and pre-existing conditions provisions of the Affordable Care Act (ACA), promote individual health insurance enrollment on the ACA Marketplace, and roll back regulatory actions that the administration has implemented since January 2017. Some of the specific provisions would:

  • Expand income-based eligibility for premium tax credits used to purchase individual health insurance coverage and increase tax credits for all income brackets, allowing more individuals to purchase subsidized health insurance coverage;
  • Fix the so-called “family glitch” to make it easier for low- and middle-income individuals to purchase subsidized family coverage;
  • Rescind the administration’s final rule expanding the availability of Association Health Plans (AHPs) that can circumvent many of the ACA’s consumer protections, specifically those involving Essential Health Benefits (read ANA’s comment letter on AHPs here);
  • Rescind the administration’s final rule expanding the availability of short-term, limited duration insurance plans, which are not required to comply with any of the ACA’s consumer protections (read ANA’s comment letter on short-term, limited duration insurance here);
  • Require the Department of Health and Human Services to conduct marketing and outreach for open enrollment with $100 million in annual appropriations (read ANA’s plan year 2018 open enrollment report here);
  • Establish a state-based reinsurance program that would allow states to set up their own reinsurance programs, or to use the funds to provide premium subsidies or cost-sharing support, with a federal reinsurance program as a backstop.

ANA has publicly supported many of the provisions in H.R. 1884 and has consistently promoted a bipartisan proposal – similar to the reinsurance proposal included in H.R. 1884 above – that Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) introduced in the previous Congress that would have established a similar program and restored cost-sharing payment reductions that help low-income individuals afford co-insurance and deductible costs (the Administration canceled these payments in October 2017).

The proposal that has arguably grabbed the most headlines, however, is “Medicare for All,” a general campaign slogan that was recently introduced as legislation by Rep. Pramila Jayapal (D-WA) with a Senate bill soon to follow to be introduced by Sen. Bernie Sanders (I-VT). The bill would implement an expanded government-run Medicare program and do away with much of the private insurance system currently in place (well over half of Americans currently receive health insurance through their employer or in the Marketplace).

While the legislation is consistent with ANA’s support for universal access to health coverage, there are several provisions that could negatively impact the nation’s four million registered nurses, as well as the patients for whom they provide care. Some of these include:

  • A fee-for-service program that could significantly reduce payment rates and have a trickle-down effect on Advanced Practice Registered Nurses (APRNs), who are currently reimbursed at 85% the rate that Medicare reimburses physicians for the same work;
  • A Medicare Trust Fund that could lead to uncertainty around payments and impact access to care should beneficiary access to services exceed the fiscal year budget;
  • The establishment of regional offices charged with recommending changes in provider reimbursement and establishing quality assurance mechanisms for their regions, which could lead to a patchwork of coverage and tempt providers to practice where reimbursement rates are higher.

Federal Courts Reviewing ACA Provisions

The Department of Justice on March 25 unexpectedly sent a letter to the Fifth Circuit Court of Appeals to state that the Administration fully supports the December 2018 U.S. District Court decision in Texas v. Azar that would invalidate the entire Affordable Care Act (the U.S. District Court decision was stayed pending appeal; the Administration had previously only supported striking down parts of the ACA, including pre-existing conditions provisions). This case will likely make its way to the U.S. Supreme Court for a final decision, though that decision would probably not come until 2020 or later. Invalidating the entire ACA with no plan to replace it would be extremely disruptive to the U.S. health care system and would result in enormous insurance coverage and financial losses.

On March 27, the Federal District Court for the District of Columbia threw out Medicaid work requirements in both Kentucky and Arkansas. This is the second time that Kentucky’s Medicaid work requirements have been blocked in federal court. Arkansas’ work requirements were implemented in June 2018 and have resulted in 18,000 individuals losing coverage. The same federal court on March 28 issued a ruling that rejects the administration’s final rule that expands the availability of Association Health Plans. ANA has consistently opposed expanding the availability of these plans, as they represent an end-around of the ACA’s essential health benefits requirements for insurance coverage.

ANA’s Commitment to Universal Access to Quality Health Care

ANA is committed to a pragmatic approach to ensuring universal access to quality, affordable, and accessible health care for all Americans, particularly vulnerable populations and those with pre-existing conditions. As ANA stated in a recent press release: “Universal access to a standard package of essential health care services for all citizens and residents is of paramount importance to the American Nurses Association. Nurses have a critical voice in this debate, and ANA is committed to advancing policy initiatives that provide and expand access to affordable coverage and quality care for all.”

This is the latest chapter in the decades-old health care debate – we expect that many proposals will be offered before the 2020 election. ANA will continue to be involved and actively advocate for nurses and the patients for whom they provided care.