Primary Care and Specialists Need to Know These Twin Add-On Codes by 2021

coding for E/M visit complexity

The 2019 MPFS proposed rule discussed potential add-on G codes to represent E/M visit complexity. Here’s a quick look at the intent of the proposed codes and what the final rule had to say about their implementation in 2021.

See What Happens to This Code for Specialists

In the 2019 Medicare Physician Fee Schedule (MPFS) proposed rule, CMS included possible creation of a G code certain specialists could add on to an E/M service code to capture reimbursement for visit complexity. Remember that the proposed rule also discussed the (now transformed and delayed until 2021) plan to pay the same for multiple E/M office/outpatient levels. The proposed add-on code was a way of adding reimbursement in that proposed new world of blended E/M payments.

Here’s some background on the proposed add-on code for specialists, temporarily called GCG0X:

  • The code would represent additional resource costs for specialties that have E/M visits as a large percentage of their allowed charges
  • The specialties involved generally report level 4 and 5 visits
  • The specialties often use E/M codes rather than separate codes for the treatment they provide.

The proposed descriptor listed specific specialties: Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, or interventional pain management-centered care (Add-on code, list separately in addition to an evaluation and management visit).

The proposed value for the code was based on 75 percent of psychiatric eval/psychotherapy code +90785 (Interactive complexity (List separately in addition to the code for primary procedure)), so the proposed work RVU was 0.25 with a physician time of 8.25 minutes.

What were the comments on the proposal? According to the MPFS 2019 final rule, no one commented on valuation for this code. They were all too busy commenting on the proposal to blend E/M payments. In the final rule, CMS stated the agency plans to add the code in 2021 for “visit complexity inherent to non-procedural specialty care.” Because there are a couple of years before implementation, the final rule notes there could be changes to the code and its valuation before you start using the code.

Put a Pin in This Add-On Code for Primary Care

If the previous section had you wondering about primary care, then you’ll want to know about proposed code GPC1X (Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services (Add-on code, list separately in addition to an evaluation and management visit)). Here are some more specifics on the code proposed:

  • It applies to new and existing patients
  • It can include aspects of care management, counseling, or treatment of acute or chronic conditions
  • The code applies when other codes do not cover the service provided
  • It is an add-on code used with E/M codes for visits involving primary care services.

The proposed work RVU was 0.07 with physician time of 1.75 minutes. In the final rule, Medicare stated that a few commenters questioned why the primary care code valuation was so much lower than the specialty code’s. Medicare decided to change the work RVU to 0.25 with a physician time of 8.25 minutes in the final rule, bringing the primary and specialty codes in line with each other. The plan is for this primary care code to be implemented in 2021, so again the code and valuation may change before then.

What About You?

Do you like the idea of using these add-on codes when E/M codes begin to see blended rates? Or do you need to see more details before you decide?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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