Regulatory Alert: CMS Increases Telehealth Payments and Makes ACO Changes

Originally published on April 30, 2020 by MGMA
Reprinted with permission from MGMA

Today, the Centers for Medicare & Medicaid Services (CMS) issued another round of regulatory waivers through an interim final rule intended to expand care to Medicare beneficiaries and provide more flexibilities to the providers that treat them. The changes outlined below will be effective for the duration of the COVID-19 public health emergency (PHE).

Changes to telehealth policy:

  • Following MGMA advocacy, CMS is increasing payment for audio-only telephone E/M services (CPT codes 99441-99443) such that they are paid at the same rate as similar office and outpatient E/M visits, resulting in increased payments from $14-$41 to $46-$110. CMS believes that the resources required to furnish these services during the PHE are better captured by RVUs associated with level 2-4 established office/outpatient E/M visits. CMS is not increasing payment for CPT codes 98966-98968, which are intended for practitioners that cannot separately bill for E/M. This policy is retroactive to March 1, 2020.
  • For telehealth services other than CPT codes 99441-99443 and 98966-98968 (now added to the list of covered telehealth services), Medicare continues to require modalities that have both audio and video capabilities.
  • CMS is forgoing its typical rulemaking process to add new services to the list of Medicare services that may be furnished via telehealth. Instead, CMS will add new telehealth services on a sub-regulatory basis to speed up the process of adding codes to the list.

Changes to Medicare Shared Savings Program (MSSP):

  • There will be no application cycle for a Jan. 1, 2021 start date, and ACOs in the last performance year of their current agreement period (mainly Track 1 ACOs and Track 1+ Model ACOs) will be allowed to voluntarily extend their agreement period by an additional performance year in 2021.
  • ACOs participating in the BASIC track glide path will be permitted to maintain their current risk level under the BASIC track for PY 2021 and freeze progression to higher risk.
  • CMS is removing all Part A and B payment amounts for episodes of care involving the treatment of COVID-19 for the purposes of determining benchmark year and performance year expenditures.
  • The list of primary care services used for beneficiary attribution will be expanded to include additional telemedicine services.

MGMA Government Affairs will continue to inform medical groups as the Administration releases additional waivers and further guidance on COVID-19 related regulatory changes. CMS’ press release on the changes can be found here and a fact sheet on MSSP changes can be found here.

Regulatory Alert: CMS Announces New Flexibilities

Originally published on March 31, 2020 in MGMA’s Washington Connection
Reprinted with permission from MGMA

Last night, the Centers for Medicare & Medicaid Services (CMS) issued a series of temporary regulatory waivers to further support the ability of the nation’s healthcare system to respond to COVID-19. The changes outlined below will take effect immediately across the entire country:

  • New telehealth codes. CMS will pay for 80 additional telehealth codes, including home visits, emergency department visits, and therapy services. Providers can waive copayments for all telehealth services for Original Medicare beneficiaries.
  • Virtual check-ins. Clinicians can provide virtual check-in services (HCPCS G2012, G2010) to both new and established patients. Previously, these services were limited to established patients only.
  • Telephone codes. CMS will reimburse for telephone evaluation and management services provided by a physician (CPT 99441-99443) and telephone assessment and management services provided by a qualified nonphysician healthcare professional (CPT 98966-98968). These codes are only available to established patients but may be furnished using audio-only devices.
  • E-visits. Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits (HCPCS G2061-G2063). These codes are only available to established patients and must be initiated by the patient.
  • Removal of frequency limitations on Medicare telehealth. Subsequent inpatient visits (CPT 99231-99233), subsequent skilled nursing visits (CPT 99307-99310), and critical care consult codes (CPT G0508-G0509) no longer have limitations on the number of times they can be billed.
  • Medicare physician supervision requirements. Physician supervision can be provided virtually using real-time audio/visual technology for services requiring direct supervision by a physician or other practitioner.
  • “Stark Law” waivers. CMS is implementing waivers that exempt providers from sanctions for noncompliance of certain Stark Law rules, permitting certain referrals and the submission of related claims that would otherwise violate the Stark Law.
  • MIPS flexibilities. CMS will allow clinicians adversely affected by COVID-19 to submit an application to request reweighting of the MIPS performance categories for the 2019 performance year.

MGMA Government Affairs will continue to educate medical groups as the Administration releases additional waivers and further guidance on COVID-19 related regulatory changes. For a comprehensive list of Medicare telehealth waivers and regulatory developments, please click here.

Partnering for the People of North Carolina

2018 Alliance sponsor feature article provided courtesy of UnitedHealthcare

From technology and patient needs to payment models and innovative partnerships, trends are converging in a rapid and exciting fashion. We’re all in it together: patients, physicians and care providers, and payers. UnitedHealthcare Community Plan shares your commitment to delivering a superior patient experience and improving health outcomes.

We believe that the best solutions come when we work together with care providers. We share the power to chart a new path, creating a stronger health care system that works better for everyone. And we’re ready to support you with tools and data resources designed to help you serve your patients and allow your practice to thrive.

Our Promise to the people of North Carolina:

Health care is constantly changing in North Carolina and throughout the country, and all stakeholders – individuals, care providers, community partners and federal and state governments – feel the impact. In the face of this changing landscape, the business and social mission of UnitedHealthcare will always remain the same: To help people live healthier lives and to help make the health system work better for everyone.

We have a long history in the great state of North Carolina and are proud of our record improving the health of more than 1.4 million people we are privileged to serve through the delivery of quality, cost-effective health care. We are committed to continuing to serve North Carolinians and working together to move the new Medicaid program forward today and for the future.

UnitedHealthcare has update its After-hours reimbursement policy for commercial plans in North Carolina

Beginning July 1, 2018, UnitedHealthcare will reimburse Primary Providers for CPT Code 99051 “Services provided in the office on evenings, weekends or holidays when Office is normally schedule to be open” when billed with a non-preventative office visit.

  • 99051: Eligible expenses for after-hours health services will be reimbursed at a value determined using the alternate of (‘gap-fill’) Fee Source as CMS does not publish an RVU value for the code.

This policy update will be effective for claims with dates of service July 1, 2018 and after. A national policy update will be implemented later in 2018.

If you have any questions about this policy update please contact Provider Relations at and include your practice name, tax ID number and National Provider Identifier to assist us in identifying your assigned Advocate. The reimbursement rate for CPT code 99051 will be available via the fee schedule lookup tool in Link beginning 07/01/2018.

Summary of 2017 CPT Changes

By Nancy M. Enos, FACMPE, CPC-I, CPMA, CEMC, CPC, Enos Medical Coding

The following is a summary of the changes coming to CPT in 2017:

Moderate Sedation

99151-99157 Moderate Sedation code section has been replaced, (prior codes 99143-99150 are deleted). A careful review of Appendix G will prepare practices to separately report Moderate (Conscious) Sedation. This change decreases the value of the codes listed in Appendix G and will require separate documentation of the patient age and sedation time to code 99151-99157. The new codes are based on age groups (younger or older than age 5) and time increments of 15 minutes.

Evaluation and Management changes

Two new medicine codes have been added to replace 99420 (Administration of Health Risk Assessment instrument). The new codes are found in the Medicine Section for a patient focused (96160) or a patient caregiver focused (96161) questionnaire.

Physical Therapy

New Physical Therapy (PT) Occupational Therapy (OT) and Athletic Training (AT) codes have been introduced and now include reporting of three levels of evaluation and one re-evaluation, based on several factors including a patient history and an examination with development of a plan of care. The three levels of clinical decision making are low, moderate and high complexity using a standardized patient assessment instrument. The definitions of the extent of physical examination and complexity of decision making are unique to Physical Medicine and Rehabilitation and do not match the Evaluation and Management definitions of these terms.

The tiered evaluation codes provide the opportunity to base coding on decision making instead of the episode of care (old codes were described as “initial” and “Re-Evaluation”). Codes 97161-97164 (PT), 97165-97168(OT), and 97169-97172 (AT) are resequenced code numbers that appear before the Modalities subsection.

Surgery changes

Spinal Instrumentation codes have been replaced to identify intervertebral biomechanical devices and interspinous process stabilization devices. Refer to section 22853-22859 and 22867-22870.

Laryngoplasty code 31582 has been replaced by 4 new codes describing surgery for laryngeal stenosis (congenital or acquired) by several methods (31551-31554). New codes 31591 and 31592 describe procedures on the larynx to treat weakness or stenosis.

Endovenous ablation therapy code report a combination of mechanical and chemical methods to ablate the veins (36473 and 36474)

New Dialysis Circuit codes (36901-369096) A new subsection of nine codes report services that allow repeated access to blood vessels to perform hemodialysis. CPT code report two segments of this service, the peripheral dialysis segment and the central dialysis segment. The definitions and guidelines for the new codes cover 2 full pages and should be reviewed before using the new codes. Watch for bundling of imaging and radiological supervision and interpretation (S&I) required to perform the angioplasty.

Spinal injections (62320-62327) series reports epidural and subarachnoid injections, with or without imaging guidance, reported by spinal region. These codes replace 62311-62318.
Transluminal balloon angioplasty codes have been replaced with four new codes (37246-37249) that replace the eight deleted codes that streamline reporting and include all necessary imaging and radiological S&I.


Mammography codes have been simplified and there are new three new codes to replace five deleted codes. Each of the three new codes include computer-aided detection (CAD). Two codes report diagnostic mammography (77065 unilateral and 77066 bilateral) and 77067 reports bilateral screening mammography with CAD detection when performed.

Pathology and Laboratory

Drug screening codes have been expanded to report screening based on the method ()80305-80307). New guidelines say to report the new codes only one per test regardless of the number of drugs classes tested. New codes for genomic sequence analysis have been added to identify cardiac conditions, fetal chromosomal abnormalities and central nervous system infection.

Medicine Section

Several vaccination codes have been revised to eliminate age from the description, such as nine influenza codes, and are now reported by dosage.

Psychotherapy codes 90832-90838 have been revised to include time with informants. CPT 90846 and 90847 are reported with “utilizing family psychotherapy techniques focusing on family dynamics” with or without the patient present. Time duration for this code is 50 minutes, and may be reported with the time exceeds 26 minutes (rounding rule).

Cardiovascular codes have been introduced to report repair of paravalvular leak, based on the site of the leak (mitral valve or aortic valve) using 93590-+93592.

Palmetto GBA E-mail Update: Wednesday, November 02, 2016

Billing for Influenza: New CPT Code for Flucelvax
The American Medical Association issued a new Current Procedural Terminology (CPT) code for influenza vaccine Flucelvax effective August 1, 2016 for Medicare claims. However, Medicare claims processing systems will not be able to accept the new code until January 1, 2017. CMS has released new guidance stating that the not otherwise classified (NOC) code will not be accepted. CMS is instructing providers to hold claims for this code until January 1, 2017.

Palmetto GBA E-mail Update: Monday, October 03, 2016

Managing Multiple eService Accounts Just Got Easier with Account Linking!
Palmetto GBA is excited to announce the highly anticipated eService enhancement- Account Linking! No longer will providers need a separate login for each PTAN and NPI combination. Palmetto GBA now gives users the ability to link their previously assigned eServices user IDs under one default ID. Getting started is simple! Users should log into eServices with the user ID that they wish to designate as their default login ID. This is the user ID that will be used to access the linked accounts. Once the user has successfully logged into eServices, they will select the My Account Tab and then access the Account Linking sub-tab. This will allow the provider to choose the accounts they wish to link.

Applies to:

  • JM Home Health and Hospice//General
  • JM Part A//General
  • JM Part B//General

Billing for Influenza: New CPT Code 90674
The American Medical Association issued a new Current Procedural Terminology (CPT) code for influenza vaccine Flucelvax, CPT 90674, effective August 1, 2016 for Medicare claims. However, Medicare claims processing systems will not be able to accept the new code until January 1, 2017. If you bill institutional claims, note that code CPT 90674 will be implemented on February 20, 2 017. Claims may either be held or you can check with your MAC for this information and other interim billing instructions.

Applies to:

  • JM Home Health and Hospice//General
  • JM Part A//General
  • JM Part B//General
  • Railroad Medicare (RRB)//General – Railroad Medicare