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Effective January 1, 2020, several changes have been made to payment policy, coding, and reimbursement.  Several new codes have been added to the CPT codebook and the Centers for Medicare and Medicaid Services (CMS) has approved new payment rates for several physiatry services as published in the 2020 Medicare Physician Fee Schedule (MPFS).  The fee schedule, updated annually, includes payment policy and reimbursement information for all codes billed to Medicare Part B.  Your Academy monitors the annual proposed changes to the fee schedule and submits comments which CMS considers in its final rulemaking process. 

PM&R 2020 Coding Changes and Payment Updates

The following is a summary of the coding and reimbursement changes affecting physiatrists effective January 1, 2020.  The 2020 conversion factor, which is used to determine payment for Medicare services, is finalized at $36.0896, an increase of approximately $0.05.  Note that total payment listed in this article is rounded to the nearest whole dollar and reflects national payment in the non-facility setting.  Practice expense RVUs are also listed for the non-facility setting only.  Payment will differ based on locale.  Also note that payment is specific to Medicare Part B; commercial payer rates will differ.

New Codes for Genicular and Sacroiliac Joint Injection and Destruction/Ablation

One of the most significant changes for 2020 is the creation of four new CPT codes for procedures physiatrists regularly perform.  Two new codes have been added to describe the injection or destruction of genicular nerves.  An additional two codes have been added to describe the injection or destruction of the nerves innervating the sacroiliac joint.   The creation of these codes depended on countless hours of work by our member volunteers who collected supporting evidence, created code applications, reviewed member survey data regarding appropriate values, and argued in support of these services at the CPT and RUC meetings.  A huge thank you to our CPT and RUC volunteers for their hard work!

New Codes for Dry Needling

Two new codes have been added to the CPT codebook describing dry needling.  These services are considered “non-covered” under Medicare.  However, CMS has assigned a value to the services as a means of guiding private payors who may choose to pay for dry needling.  Please check with your payor to determine if they will reimburse for this service. 

Somatic Nerve Injection Codes – Changes to Payment

The CPT and RUC recently reviewed the somatic nerve injection family of codes and recommended new language and values for these services.  Code language has been clarified to indicate that regardless of how many of a certain type of injection you perform, each code is billed only once.  Further, a table has been added to the CPT codebook to clarify which injection codes include imaging and which codes require separate billing of imaging if performed.  Additionally, the codes for intercostal nerve injections have been updated to include an add-on code when injections are provided at more than one level (see codes 64420 and 64421).  Many of the somatic nerve injection codes had not been reviewed by RUC since the 1990s.  Unfortunately, the reimbursement for many of these services will decrease as a result of this revaluation (some codes retained their current value).  Note that while the entire family of codes has been reviewed, the table below only reflects those procedures which PM&R bills with any regularity.

Intrathecal Pump Analysis and Programming Codes – Changes to PE

Practice expense for the intrathecal pump and programming codes was reviewed by the RUC.  Based on this re-review, CMS has implemented decreased practice expense values for these codes resulting in decreased payment overall.

Ultrasound of Extremity – Changes to PE

As previously reported in 2018 and 2019, practice expense for ultrasound code 76881 has changed.  In the 2018 MPFS final rule, CMS finalized a proposal to revise practice expense inputs for both ultrasound codes.  For the complete joint ultrasound code, 76881, CMS determined that this service is no longer typically performed in a dedicated ultrasound room or using a PACS workstation.  Because of these changes, CMS finalized a significant decrease to practice expense, which will be implemented over a series of years beginning in 2018.  In 2020, total payment for 76881 has decreased by approximately $11.  A similar cut is expected for 2021.  Changes to 76882 for 2020 total less than $0.50. 

New Codes for Principal Care Management

CMS finalized payment for two new codes for “principal care management.”  The codes describe work done over the course of a calendar month to care for patients with a single high-risk disease.  Payment reflects work done in 30 minutes or more to create and maintain a care plan and coordinate care for the patient.  Patient visits and any procedures performed on the patient would be separately billable.  These codes were developed by CMS and therefore are not found in the CPT codebook at this time.  Instructions for how the codes are intended to be used can be found in the MPFS Final Rule, however we anticipate that CMS will publish additional guidance on these codes in the form of an online article. 

The two codes are distinguished based on provider: code G2064 is paid at a higher rate and requires 30 minutes of physician or other qualified healthcare professional time per calendar month; code G2065 is paid at a lower rate and requires clinical staff time only. 

The services require the following elements:

• One chronic condition lasting at least 3 months, which is the focus of the care plan
• The condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization
• The condition requires development or revision of disease-specific care plan
• The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

2020 Policy Changes Impacting PM&R

Several changes were made to CMS and CPT policy which will impact PM&R coding, billing and documentation in 2020. 

Modifier 50 – Bilateral Procedures and Add-on Codes

Effective January 1, 2020, the CPT codebook is implementing new guidelines for the billing of modifier 50 for bilateral procedures in conjunction with add-on codes.  Effective this year, add-on codes cannot be billed with modifier 50 to denote bilaterality.  Instead, when the add-on procedure can be reported bilaterally and is performed bilaterally, the add-on code should be reported twice.  Coders should also review the add-on code descriptor, guidelines and parenthetical instructions for additional information if available. 

Physician Supervision for Physician Assistant (PA) Services

In the 2020 MPFS Final Rule, CMS finalized a proposal designed to enable PAs to practice more broadly.  AAPM&R opposed this proposal in our comment letter to the MPFS proposed rule.  The Academy comment highlighted concerns about patient care resulting from lack of oversight of PA services.  Effective January 1, 2020, rather than restricting PAs to a national Medicare supervision requirement, CMS will allow PAs to provide professional services according to state law and state scope of practice rules set by the state the PA is practicing in.  For states with no explicit law or scope of practice rules, CMS has defined supervision as “a process in which a PA has a working relationship with one or more physicians to supervise the delivery of the health care services.  Such physician supervision is evidenced by documenting at the practice level that PA’s scope of practice and the working relationships the PA has with the supervising physician/s when furnishing professional services.”