9 Changes Coming to Medical Billing in 2016

This fall brought a bevy of changes to physician reimbursement. Within a matter of days, the Centers for Medicare & Medicaid Services (CMS) issued the Final Rule for the 2016 Medicare Physician Fee Schedule, and fundamental changes to the EHR Incentive Program for 2015. These announcements came just days after the implementation of ICD-10, and were soon followed by the government’s Bipartisan Budget Act of 2015 which incorporated key changes to healthcare reimbursement.

Given the breadth and depth of the changes, let’s review the modifications that may impact your practice in 2016 – and beyond: 

1.  A small increase—0.5%—was in place for January 1, 2016, but CMS’ efforts to revalue codes (a 0.77% reduction) offset this near-term bump in payment.
2. After proposing to require the billing physician also be the supervising physician, CMS backed off the proposal, stating that the “physician (or other practitioner) directly supervising the auxiliary personnel need not be the same physician (or other practitioner) that is treating the patient more broadly…”
3. The date of service for transitional care management (TCM) codes will now be the date of the visit, versus the end of the month. CMS revealed that the claim can be released on that date as well, thus streamlining the billing process.
4. CMS confirmed that it will cover advanced care planning (ACP), and set the work RVUs to be 1.50 (99497) with 1.40 for each additional 30 minutes (99498). However, the codes are subject to cost-sharing for the patient (unless billed at the time of the patient's Annual Wellness Visit, noting that the ACP services should be billed with a modifier -33 in this case and are separately payable) and must be performed by a physician, advanced practice provider (APP), or via incident to under the direct supervision of a physician or APP.
5. More telehealth services are placed on the "paid" list by Medicare including prolonged service inpatient CPT codes, 99356 and 99357, and end stage renal disease (ESRD)-related services 90963 through 90966, with the originating telehealth site reimbursed a $25.10 facility fee for each patient.
6. The government’s incentive programs were updated with new measures in the Physician Quality Reporting System (PQRS) and the Shared Savings Program, and a modification of the Value-based Payment Modifier (VBPM). To address “reliability concerns,” the minimum number of patients is increased to 125 to include the practice in the cost assessment. Further, solo practitioners and small groups won’t be subject to the VBPM’s all-cause hospital readmissions measure in 2017 and 2018.
7. Although there are specific parameters to follow, CMS is allowing hospitals to provide financial assistance to physicians in hiring APPs as a new exception to the physician self-referral law. Social workers and clinical psychologists are also included, with CMS revealing that subsidies are limited to situations in which the APP is providing primary care or mental healthcare services.
8. The bipartisan budget deal included key elements impacting the healthcare industry. As has been done in years past, the sequestration cuts were tacked on for yet another year, making those 2% reductions to all Medicare payments extend until 2025. Practices that are currently designated as hospital outpatient departments (OPDs) under Medicare’s provider-based billing are grandfathered, but any new OPDs that are physically off the hospital’s campus—defined as 250 yards—will not get an extra payment from Medicare as of January 1, 2017. “New” is considered those OPDs established (and billing claims) as of November 2, 2015, the date the bill was signed into law. These off-campus OPDs won’t be hard to distinguish, because CMS is already requiring a new place of service code – 19 - for off-campus OPDs as of January 1, 2016.
9. And, finally, there are more than 350 code changes—140 new, 93 deleted, 134 revised —to 2016 CPT®. The American Medical Association clarified the existing prolonged services codes, as well as created two new codes to report prolonged, face-to-face clinical staff services under the direct supervision of a physician or advanced practice provider—99415 and 99416—when the time spent by your staff consumes 45 minutes or more. Furthermore, the AMA clarifies that the behavior change intervention codes, 99406-99409, can be reported with a -25 modifier in addition to an E/M service when performed on the same day, including the preventive medicine physicals (99381-99397). A new code—69209—may come in handy to many; it’s used to report the removal of impacted cerumen using irrigation/lavage (unilateral). Previously, this service was included in the E/M code, although it’s notable that most payers have yet to release their reimbursement determination. Sigh! Having a new code doesn’t always mean you’ll get paid. Before the New Year gets rolling, please review your 2016 CPT® Manual, and check with your specialty society to get the low-down on the changes that will impact you.