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Top 5 Reasons PPS G Codes Need Code Expansion

September 19, 2016

Medicare G CodesCoding is a complex topic. So confusing is it that too many in CHC leadership fail to sometimes grasp nuances essential to broadly capturing the full breadth and scope of all services rendered. This misstep results in undervaluation of actual services rendered, diminishes staff morale due to their inability to demonstrate the volume and intensity of work done, and (most obviously) mitigates full payment opportunities.

The transition to the Medicare’s PPS G codes moved CHCs from a historic “cost based” reimbursement model to a “prospective payment system.” For those not familiar, following is quick list of these codes:

  • G0466: General medical, new patient
  • G0467: General medical, established patient
  • G0468: Initial Periodic Preventive Exam (IPPE) or Annual Wellness Visit (AWV)
  • G0469: Mental health, new patient
  • G0470: Mental health, established, patient

As a taxpayer and businessman, the transition was to me sensible for two primary reasons:

  1. The cost based system afforded a perverse incentive for CHCs to spend as much as possible on as few visits as possible to maximize their “cost per visit.”
  2. Medicare historically paid FQHCs at the encounter rate (actually, 80% of medical and 100% for preventive post ACA) even if charges were below the rate. This contradicted the industry standard of payers paying the lesser of a provider’s charges or the payer’s fee schedule.

The new PPS G code structure pays a fixed rate based on a CHCs fixed G code charges. CHCs must determine their average cost for each of the above and set a rate for their G codes. Thereafter, for a “qualifying visit” a CHC is paid the lesser of the G code charge or the PPS ceiling (i.e., for 2016, $160.60.) This is good for taxpayers and federal fiscal fiduciaries but a challenge for CHCs struggling to calculate G code charges and understand which services fall under each unique G code.

To make this more complex Medicare limited G code payment to clinic scenarios represented by a finite range of HCPCS (e.g., “CPT”) codes which must be justified for PPS payment to occur. From the initial release of this list, coding professionals have bemoaned the limited range of HCPCS codes. Below are the top reasons why this must be rectified:

  • Not all core provider services require E&M visits. Admittedly, much CHC clinical work falls under an E&M service. However, national correct coding policy stipulates that a patient presenting for a procedure only visit (e.g., toe nail repair, wart destruction, incision and drainage, etc.) should be coded and billed with only a surgical code. An E&M might also be appropriate but only if a “-25 modifier opportunity” presented (i.e., a significantly and separately identifiable issue was addressed at the time of the procedure). Further, other covered Medicare services like chiropractic or osteopathic manipulative treatment are correctly coded with just a “subluxation” or “manipulation” code, again without an E&M service. Under the present coding system, these services are rendered by CHCs without CHCs receiving payment. In fact, the majority of the excluded codes are from largest section of CPT; i.e., the surgical section representing CPT codes 10000-69999.
  • Compelling less seasoned coding/billing focus to code/bill incorrectly. Most CHCs are admittedly substandard around coding. Their historial “encounter rate” payment made it seem pretty insignificant. However, CHCs well understand the encounter rate or “qualifying visit” payment “trigger” which has been a face-to-face encounter between a patient and a core provider. This consultant fears too many are now adding an E&M service just to trigger this payment.
  • Inabilty to capture full breadth and scope of services. The over capture of E&M because of item 2. herein, is not only inappropriate coding but it undermines the integrity of data capture intended to understand what services CHCs are actually providing. Change Request 7038 (January 2011) was created so CMS could evaluate all the services CHCs are offering. This present PPS G code limitation around HCPCS is antithetical and sends an incredibly mixed message to CHCs.
  • Handicapping CHCs ability to prepare for MIPS. HCPCS (again, think CPT) are used for risk-determination/underwriting by third party payers when working in the professional vs. facility realm. In other words, professional vs. facility providers (e.g., CHCs) paid under the Part B, CMS 1500, and ANSI 837-P models have “risk” evaluated based on the HCPCS codes captured. This is incredibly significant as CHCs prepare for Alternate Payment Methodologies (APM) under MACRA/MIPS and other state managed Medicaid models. While we understand MIPS will mostly focus on fee for service (FFS) dollars paid under the professional fee schedule (PFS), CHCs expect PPS (both Medicaid and Medicare eventually) to eventually be impacted. How can CHCs get a fair shake in terms of capture of all services if the code list they are allowed to submit is so truncated?
  • Discrimination against Medicare beneficiaries. In an effort by CMS to assist CHCs with questions or issues around the PPS G codes, a FAQ document was published. Aside from the “new patient” definition contradicting CPT text (and all other payers in the healthcare world) and too many MAC staff not even understanding what a CHC is/does, page 8, question 9 seems to clearly set precedent for CHCs to discriminate against Medicare patients seen at their offices by compelling the patient to sign an Advanced Beneficiary Notice (ABN) and pay cash for a service covered by CMS in any other outpatient (Part B) setting. Here are two very real scenarios:
    • Medicare beneficiary with Type 2 Diabetes arrives for medical necessary toenail debridement. No other issues exist. The core provider performs the service and codes 11720-11721 depending on how many nails are debrided.
    • Medicare beneficiary with an inflamed boil arrives today after being seen yesterday. S/he has taken oral antibiotics and arrives today to have the boil incised and drained. CPT code 10060 is the standalone code as no other services are rendered.

How can CMS compel CHCs to charge a Medicare patient cash for a service covered in any other setting?

At this moment in time, CHCs should be writing congressman and senators while asking patients to do the same. Certainly the omission of these codes was simply an oversight. However, the unintended negative consequences are dramatic, far-reaching, and discriminatory. Let’s hope some collective “calls to action” can result in rapid rectification of this avoidable aberration.

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