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PFS Billing-Code Rules 'A Step Forward,' Says AOA

Analysis  |  By Christopher Cheney  
   November 07, 2016

New billing-code rules for primary care physicians who treat Medicare patients will increase payments for medical services that are rendered outside of face-to-face office visits.

New Medicare payment rules for physicians set to start on Jan. 1 are a positive development for primary care practices, the American Osteopathic Association says.

Several provisions of the 2017 Physician Fee Schedule final rule are designed to boost payments to primary care practices for non-face-to-face care management, care coordination and cognitive impairment services, according to a Centers for Medicare & Medicaid Services fact sheet released last week.

CMS released details about the 2017 PFS final rule on November 2.

CMS Finalizes 2017 Outpatient-Service Payment Rules

"CMS is finalizing several revisions to the PFS billing code set to more accurately recognize the evolving work of primary care and other cognitive specialties to accommodate the changing needs of the Medicare patient population," the fact sheet says.

"Historically, care management and cognitive work has been 'bundled' into the evaluation and management visit codes used by all specialties. This has meant that payment for these services has been distributed equally among all specialties that report the visit codes, instead of being targeted toward practitioners who manage care and/or primarily provide cognitive services."

Laura Wooster, MPH, interim senior vice president for public policy at the AOA, told HealthLeaders last week that her organization is cautiously optimistic about the billing code changes in the 2017 PFS final rule.

"In terms of what they have done previously, this does feel a little different. We are pretty optimistic that this will be a step forward. The devil will still be in the details though. Some of these codes will be complicated to educate our members on so that they can take full advantage of them," she says.

Allowing primary care physicians to bill for more medical care services that are conducted outside of face-to-face visits with patients is a significant improvement of the PFS, Wooster says.

"What had happened previously was that by having services bundled into an evaluation and management visit code, it made those codes available to all specialties, which was a good thing when physicians had to do additional specialty work. But it also made it harder for primary care, which has a certain level of care beyond [face-to-face interactions with patients]."

She gave a hypothetical example of how the new codes will work. "With one of the codes for the non-face-to-face time, the physician will have to document an hour of time in order to be paid for that code. In practice, that hour could be reconciling the 20 different medications a patient is on to make sure two of them are not conflicting with each other and making the patient worse."

"That takes time. Some of it could be care coordination in terms of reaching out to other physicians and specialists that the patient is seeing, then doing follow-up and getting care plans to see whether there is any reconciling that needs to be done there. A lot of that back-end work is not part of the usual visit code."

The new PFS billing-code rule for cognitive-assessment reimbursement should help patients and give primary care practices a financial boost, Wooster says.

"One of the other codes that we were happy to see lets physicians to be paid for cognitive assessments. So, if physicians have elderly patients, they can take the time needed to do cognitive assessments to see whether patients have the early stages of senility or Alzheimer's or dementia, then physicians can get paid for taking the time to do those assessments.

"There is limited time in most visits—about 14 minutes—so the cognitive assessment code allows physicians to take the extra time and still stay in business."

The billing-code changes and other provisions of the 2017 PFS final rule are expected to increase Medicare payments to primary care practices about $140 million next year.

Christopher Cheney is the CMO editor at HealthLeaders.

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