Capitol Beat

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Medicare E/M codes July 2018 in the CY 2019 PFS proposed rule to address the common perception that the E/M codes were outdated and to achieve administrative simplification.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.

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