Billing Coding 2021 Dermatology PAs NPs
A proposed bill before Congress would put a 2-year freeze on Medicare services set for 2021 pay cuts.
The bill, known as the “Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020” (H.R. 8702), would effectively freeze payments at 2020 rates for services scheduled to be cut in 2021 for a period of two years, while allowing the planned E/M payment increases to take place as scheduled. The 2021 Medicare Physician Fee Schedule (PFS), set to take effect January 1, 2021, has PAs and NPs seeing an 8% increase in office visit E/M reimbursements. This bill would allow these payments to proceed as scheduled, but not at the expense of steep payment cuts elsewhere. Keep an eye on the bill’s progress here:
https://www.congress.gov/bill/116th-congress/house-bill/8702
E/M Changes in Early 2021 for 99202-99215
Effective January 1, 2021, extensive E/M coding changes will take place that include additions, revisions, and restructuring to the code set.
Amongst those changes:
1. 99201 has been eliminated and 99211 has been designated as a visit that does not usually require provider involvement.
2. New and established patient E/M codes will now be based on total time or medical decision making (MDM). The clinician may choose to bill based on time or MDM for each patient.
3. When using MDM to select E/M Code:
Neither history nor exam are determining factors in selecting the level of service when billing for MDM. All codes require a medically appropriate history and/or examination, but will no longer contribute to code level selection. E/M code selection will be based on the complexity of the medical decision making and will be broken down into straightforward, low, moderate, or high-level medical decision making. Complexity is determined by:
• Number and complexity of problems addressed
• Amount and/or complexity of data reviewed and analyzed
• Risk of complications, morbidity, mortality with patient management
4. When billing for total time:
The total time does not necessarily have to be all face-to-face and will no longer require the service to be dominated by counseling. Visits will have an associated time range, i.e. 99203 will require 30-44 minutes. Tasks that contribute to total time on the date of the encounter include, but are not limited to:
• Ordering medications or tests
• Time spent preparing to see the patient
• Documenting in the electronic health record
More information about E/M code changes can be found here: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
“Incident to”: Do You Understand the Rules?
One of the most common billing questions that PAs and NPs have focuses on billing “incident to.” Being familiar with “incident to” guidelines is critical for accurate billing and avoiding allegations of fraud and abuse. In today’s busy dermatology clinic, billing “incident to” is difficult to achieve and should be used with caution.
“Incident to” is a Medicare billing provision that allows reimbursement for services delivered by PAs and NPs at 100% of the physician fee schedule, as opposed to the typical 85%, provided certain criteria are met. Key aspects of this criteria include:
1. The physician must be in the suite of offices when a PA/NP renders the service.
2. The physician must personally treat the patient and establish the diagnosis on the patient’s first visit or for any established patient who comes to the practice with a new medical condition. PAs/NPs are then allowed to see the patient on subsequent visits for the purposes of billing “incident to.” Keep in mind:
• This essentially eliminates the ability for PAs/NPs to independently treat new patients if billing “incident to.”
• “Incident to” could also prove difficult in a situation when the patient was scheduled to be seen for an established problem but brings up a new problem during the course of the visit. Once a new problem is introduced, the visit cannot be billed “incident to.”
• Billing “incident to” is not as simple as having a physician “pop in” to the visit or documenting “physician examined the patient and agrees with treatment plan” in the EHR.
3. When billing “incident to,” the physician assumes responsibility for the overall care of the patient and should be an active and ongoing participant in the management of the patient.
4. Most importantly, billing “incident to” makes it difficult to accurately quantify the services delivered by PAs and NPs, as the services are “hidden” under the physician’s NPI.
Only you and your physician can determine if billing “incident to” is right for your practice; communication and a working knowledge of the criteria is key for making this decision.
Eileen Cheever MPAS, PA-C, resides with her husband Aaron in Lunenburg, Massachusetts. She works at Clearview Dermatology in Leominster, Massachusetts. In her spare time, she enjoys cheering on her favorite Boston sports teams and exploring the outdoors with her husband and their dog, Jasta.