What Wound Clinics Need to Know about the New OPPS Rules

Some welcome flexibilities and administrative relief are built into the final 2021 Medicare Outpatient Prospective Payment System (OPPS) rules for paying wound care professionals and outpatient hospitals. While some of the telehealth policies are being made permanent, CMS makes it clear that it does not have authority to continue telehealth benefits for patients in homes or in originating sites in urban areas after the end of the public health emergency (PHE). Continuing telehealth to Medicare patients in homes and in non-rural areas will require congressional action. 

Below is a summary of updates your clinic may need to be aware of.

NPP Supervision Rules

Flexibilities that are permanent for 2021 include enabling non-physician practitioners (NPPs) such as physician assistants and nurse practitioners to supervise other staff performing diagnostic testing.  This will help practices and hospitals alike extend the reach of these healthcare professionals. Also, to the end of 2021, physicians and NPPs can provide supervision of office staff via audio/visual telecommunications.  For outpatient hospitals, CMS completed enabling all therapeutic services to be furnished under general supervision when the services are appropriate for hospital staff to perform.

For medical record documentation, CMS clarified that not only physicians and NPPs but also other clinicians, such as therapists, can review and verify documentation by any members of the medical team caring for a patient.  Documentation by team members would need to support the codes of the billing professional’s services. Documentation that can be reviewed and verified includes that made by therapy students, and students of other disciplines, working under any other physician or practitioner who furnishes and bills directly for their professional services, so long as the documentation is reviewed and verified (i.e., signed and dated) by the billing physician, practitioner, or therapist.

Virtual Check-in Codes

Another permanent change is that virtual check in codes that can be furnished to patients in homes at all times will continue to be payable to physicians and NPPs with G2010-G2012 codes, but also therapists and other clinician types can continue to furnish these services beyond the PHE. To differentiate these clinician types from physicians and NPPs, CMS established new HCPCS codes for their billing (i.e., G2250 and G2251) and CMS heard from physicians that a 10 minute virtual check-in is often difficult, so CMS also established HCPCS code G2252 for 11-20 minutes of a virtual check-in. During the PHE this can be furnished to new and established patients, but once the PHE ends, virtual services are only enabled for established patients.  Wound care professionals, to reduce infection risks, should take full advantage of virtual check-ins with patients.  Remember, these services also require patient consent.

2021 AMA CPT Changes

The long anticipated 2021 AMA CPT changes for office/outpatient E/M codes (i.e., 99202-99205/99211-99215) are now imminent, eliminating the need for outdated CMS 1995/1997 documentation guidelines for these codes.  Unfortunately, the outdated guidelines continue to apply to all other types of E/M services such as inpatient, observation and emergency department visits. All payers must follow the AMA CPT guidance for these codes because of the administrative simplification laws of the Health Insurance Portability and Accountability Act (HIPAA).

However, one unanticipated impact of the decision to increase the relative value units (RVUs) for these codes was the decision to increase RVUs for many other codes.  Due to the statutory requirements of no inflationary update to physician payments for 2020-2026 and the additional budget neutrality requirement of the statute, the dollar conversion factor was slated to decrease by 10% because the entire physician fee schedule is designed to be a zero sum game – no increase or decrease in payment due to RVU changes. However, at the last-minute, Congress stepped in with a 3.75 percent increase in the Consolidations Act of 2020.

Without the Congressional action, the impact of the changes ranged from a high of plus 16% for endocrinology to a low of minus 10% for nurse anesthetists. The impact on each physician, NPP and group practice needs to be estimated based on their own Medicare billing history and the new payment rates because even with the 3.75% increase to the conversion factor, it is still a 3.3% decrease from the 2020 conversion factor.  Hospitals are impacted as well because when hospitals bill outpatient services of employed therapists, psychologists, nutritionists, etc., the payment made by Medicare is from the physician fee schedule rather than from the hospital outpatient payment system. There is an estimated decrease in payment for outpatient therapy to Medicare patients that will still need to be estimated.

Delay of G2211 Add-on Code

For wound care, there is delayed implementation of another CMS plan to pay for complex patient care management with add-on code G2211. The Consolidation Act of 2020 also delayed this code, which was to be available to be used with any level office/outpatient E/M code new or established for the additional care. Managing patients with a single complex problem and likely many wound care patients would qualify. 

What is effective January 1, 2021 for those encounters where significant office/outpatient time requires billing at the highest levels of 99205 or 99215, is the add-on HCPCS code G2212 for each 15 minutes of new prolonged office/outpatient time. For Medicare patients, G2212 is to be used in lieu of the CPT code 99417 due to differences between CMS and the AMA about how to count time when reporting prolonged services. CMS requires an additional 15 minutes beyond the maximum time threshold and AMA allows the first 15 minutes of time to be counted beyond the minimum time threshold so caution is advised since the two codes cannot be cross walked.

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