CMS Enters 2021

Earlier this month, ACCC held an online Oncology Reimbursement Meeting hosted by Teri Bedard, RT(R)(T), CPC, Director of Client Services at Revenue Coding Strategies, Inc. Bedard reviewed the Outpatient Prospective Payment System (OPPS) and Physician Fee Schedule (PFS) rules recently finalized by the Centers for Medicare and Medicaid Services (CMS) and discussed the impact they will have on oncology practices, freestanding cancer centers, and hospital-based cancer programs in CY 2021. Among the topics Teri covered include the changing landscape of telehealth billing.

The COVID-19 pandemic has no less than transformed the delivery and reimbursement of telehealth services. Now with new vaccines being approved and shipped, healthcare providers are wondering how many of the coding and billing adjustments made to accommodate remote care will continue after the public health emergency (PHE) is declared over.

During her webinar, Bedard provided an overview of what CMS’ final OPPS and PFS rules mean for the billing and coding of telehealth services. The current PHE is set to end January 22, 2021, although it has already been extended several times. Bedard said that CMS is being cautious about a “hard and fast” return to the coding rules in effect pre-PHE, preferring to ease some telehealth modifications into removal.

In reviewing the final rules on coding for telehealth services, Bedard explained that CMS has created three levels of such services: Categories 1, 2, and 3. Items in Category 1 are permanent additions to Medicare telehealth services. Category 2 includes services that will remain temporarily on the Medicare telehealth list through the end of the year in which the PHE for COVID-19 is declared over. CMS has stated that this is to allow for the continued development of evidence to demonstrate the clinical benefits of these services and to facilitate post-PHE care transitions. Category 3 includes services that CMS is not adding to the Medicare telehealth list either temporarily or permanently. Although more than 150 codes have been added to the CMS telehealth list, CMS has declined to continue payments for audio-only patient visits beyond the end of the year in which the PHE is declared over.

At the conclusion of Bedard’s presentation, she took questions from participants, although time prohibited her from being able to answer them all. Below, Bedard answers the remaining questions asked during the webinar:

Q. Can telephone time 7 days after or 24 hours before a billed E/M be added to the E/M billing time?

A. In 2020, time is based on the time during the encounter. In 2021, the time for outpatient visits will be based on the date of the encounter. Time outside of the encounter itself in 2020, or outside the date of encounter in 2021, is not counted toward the time reported for billing the level of an outpatient visit.

Q. Regarding the Most Favored Nation (MFN) Model, if your commercial contract is based on Medicare rates, wouldn't they be affected?

A. Yes, if your commercial contracts are based on a percentage of Medicare, any time there is an adjustment to the Medicare payment rate, it can and will impact the rate contracted by the commercial payer. However, it is recommended that you review your payer contract to determine if they have a separate payment methodology specific to Part B drugs, such as payment based on the Average Sales Price (ASP).

Q. How are genetic services being handled, especially regarding telehealth visits?

A. Without knowing which genetic services are being referred to, I can tell you that the codes specific to genetic counseling are not on the approved list of telehealth services. If the CPT®/HCPCS code is not listed on the approved list, the work is provided in person per the guidelines, with the code as outside the public health emergency. If an office visit is performed, it would be billed as an E/M as appropriate. If the visit is on the approved list of telehealth services, then they would be billed as supported.

Q. Should the new M1145 HCPCS code be added to all medications automatically?

A. There are 50 drugs that are part of the Most Favored Nation (MFN) Model, and HCPCS M1145 will only be used for drugs within the model; therefore, it should not be added automatically to all medications. HCPCS M1145 is reported per drug unit with these drugs when they are billed on the claim to Medicare. CMS has advised that the M1145 code will be billed in quantity, which will be consistent with the total number of units of the drugs within the MFN Model reported on the claim for the date of service, but the code will not include units billed with the JW modifier.