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Urgent Care Coding Updates 2022? Medicare Physician Fee Schedules

Urgent Care Coding Updates 2022? Medicare Physician Fee Schedules

Physicians are required to file their annual fee schedules with CMS (Centers for Medicare & Medicaid Services) by January 1st of each year. The physician fee schedule is used to determine the amount of reimbursement physicians receive for services provided to Medicare beneficiaries. In addition, the physician fee schedule is used as a reference point for determining the amount of payment made to physicians under the Medicare program.

To implement the Medicare Physician Fee Schedules, CMS has developed two separate systems: the Medicare Physician Fee Schedule (MPFS) and the Medicare Supplier Fee Schedule (MSF). The MPFS is a national system that applies to all providers of covered professional services, including hospitals, nursing homes, durable medical equipment suppliers, hospices, home health agencies, and certain other entities. The MSF is a regional system that applies to all non-hospital providers of covered professional services.

The Medicare Physician Fee Schedule is published annually in the Federal Register and includes information regarding the amounts payable to physicians for services rendered during the calendar year. In this article, we give you a quick overview of changes to the Medicare Physician Fee Schedule that will take place on January 1, 2022.


A summary of the Physician Final Rule for 2022

In November 2021, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Physician Fee Schedule (MPFS) Final Rule. The Final Rule made further changes to the MPFS, which became effective on January 1, 2022.

Medicare reimbursement assumes-and physicians are expected to provide a full range of services and treatments that meet the needs of their patients. They are updated every year to reflect the most recent scientific evidence, changes in technology, and practice patterns. They are meant to improve quality healthcare, improve patient care, and help people get the care they need.

Medicare payment rates are updated annually based on inflation and other factors. They are subject to change on April 1 each year. More information about Medicare reimbursement can be found on the Centers for Medicare & Medicaid Services (CMS) website.

The RVUs are the relative values assigned to physician work. These values are determined by the Medicare Physician Advisory Committee, which is comprised of doctors and non-doctors with expertise in the field of health care. The RVUs attached to each service determine how much physicians earn from Medicare.

The geographic adjustment factor is based on the difference in costs of providing medical care between practice locations around the country. It can increase or decrease a physician’s Medicare payment, depending on whether the area they practice in has higher or lower practice costs than those nationwide.

Expanded Data Reporting (EDR) 10C and EDR 11C provide physicians with a single report containing their actual Medicare payments, as well as their RVUs, GPCI, adjustments, and other important information needed to submit appeals effectively. These are the national allowable, calculated based on RVUs:

Two percent Medicare cuts will also affect final payments because Congress won’t be able to stop the cuts. Lab tests, for example, are not part of the physician fee schedule, so these rates will not be affected.


Vaccine Administration

As of 2021, the cost of influenza, pneumococcal, and hepatitis B virus vaccines will increase to $30 from $17.63 on average. G0008 (influenza), G0009 (pneumococcal), and G0010 (hepatitis B) are included here. Geographic adjustments may apply.

As of January 1, the year following the end of the Public Health Emergency (PHE), COVID-19 vaccine administration and monoclonal antibody infusion services will remain at the current rates. Unless and until another extension is made, the PHE will remain in effect until January 16, 2022.


Split/Shared Services

Services that are split or shared depending on the fact sheet from the doctor and the non-physician practitioner (NPP) that was given on the date of service.

Incident-to guidelines must be followed in the office. Shared visits will be restricted to institutional settings starting in 2022.


Telehealth’s new POS

Telehealth services are now available through a new POS added by the Centers for Medicare & Medicaid Services (CMS). With the new POS 10, telehealth services are delivered to the patient’s home. POS 02: Telehealth services that are not provided in the patient’s home are also listed as POS 02. Effective April 1, 2022, this new POS will be available for use.

During the COVID-19 PHE, CMS will cover telehealth services until the end of 2023 while they continue to look at changes to the permanent policy. Practices that use load sharing will see their originating site fee, Q3014, go up a little in 2022. It will go from $27.02 to $27.59.


Physician Assistants

As part of the evolving role of non-physician practitioners (NPPs), CMS will be able to make direct payments to physician assistants (PAs). Payments are only available to the PA’s employer at the moment. Beginning January 1, 2022, PAs will be able to bill Medicare directly for professional services or integrate with other PAs and bill Medicare for PA services.


Addition of Modifier 93

On January 1, 2022, a new modifier 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) became effective. With this modifier, physicians or other healthcare professionals can report on medical services provided through audio-only communication with patients. As the name implies, synchronous telemedicine consists of a real-time, two-way conversation between a physician or other qualified healthcare provider and a patient located far from the physician. This modifier is intended for payers that prefer E/M codes instead of the time-based CPT codes 99441–99443 for billing calls.


COVID-19 Immunization Diagnosis Codes

Three new diagnosis codes were announced by CMS for April 2022, including two codes for COVID-19 vaccination status. Coding for inpatient reimbursement has primarily been designed for hospital use. A hospital’s reimbursement is based on the most frequently used resources during a diagnosis.

Z28.310 – Covid-19 unvaccinated (To be assigned to patients who have not received one or more doses of the Covid-19 vaccine)

Z28.311 – COVID-19 partially vaccinated (Assignation when the patient has received at least one dose of the multidose COVID-19 vaccine regimen but not the entire regimen)

Z28.39 – Another under-immunization status


New Code Update: 99211 Consistency Adjustment

This code descriptor will be used as of 2022, describing office or other outpatient visits for evaluating and managing established patients that do not require the presence of a physician or provider of health care. 99211 requires that these services be medically necessary (i.e., clinically indicated) and accompanied by a plan of care by a physician or other qualified healthcare professional.


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What are CPT Codes? Understanding CPT Codes

CPT is a standardized set of codes used to report medical, surgical, and diagnostic procedures and services to various entities, including physicians, insurance companies, and accreditation organizations. Medical bills are billed electronically using CPT codes combined with ICD-9-CM or ICD-10-CM numerical diagnostic codes.

The CPT codes are used to submit claims to federal and private payers when rendering healthcare. As CPT codes provide a detailed description of a procedure or service, they eliminate subjective interpretations of what was delivered to the patient.


The American Medical Association (AMA) developed CPT® codes in 1966 to standardize reporting of medical, surgical, and diagnostic services and procedures provided in hospital and outpatient settings.

The evolution of healthcare – including the availability of new services and the retirement of outdated procedures – is a significant consideration. Every year, the AMA releases new, revised, and deleted CPT® codes and changes to coding guidelines. The AMA also releases more minor updates to various sections of the CPT® code set.

Moreover, the AMA updates CPT® terminology or medical language to reflect advances in medicine. Though the AMA owns the copyright to CPT®, it invites participants to contribute to the ongoing maintenance of the code set and welcomes feedback on the codes and code descriptors.


Understanding CPT® codes

CPT® codes are composed of five characters. In general, codes are numeric, but some codes include a fifth character, such as A, F, T, or U. These are some examples:

92526      Oral function therapy

0638T      Ct breast w/3d bi c-/c+ 


CPT® Code Types: A Quick Guide

Providers assign codes to every service or procedure they perform. It even includes codes for services and procedures not specifically named in another CPT® code, called unlisted codes.

The AMA has organized CPT® codes logically by classifying them into three types based on the wide range of services and procedures they cover:

CPT® Category I: Codes commonly used by providers to report their services and procedures comprise the largest body of codes

CPT® Category II: Additional tracking codes used in performance management

CPT® Category III: Emerging and experimental codes for reporting services and procedures


CPT® Category I:

Most CPT® codes are in Category I. There are a variety of existing services and procedures that are widely used and, where appropriate, approved by the Food and Drug Administration (FDA).

In general, Category I codes, which are typically represented by five characters, are arranged numerically. Codes are resequenced in one discrepancy from the expected order. In order to facilitate quick access to related codes – and help coders select the best codes – the AMA groups similar codes together. Resequenced codes occur when a new code is added to a family of codes, but there is no sequential number assigned to it.

Another exception to numerical code order involves evaluation and management codes (E/M codes). Although E/M codes begin with 9, they are printed first in CPT® code books, as you can see below in the code outline for Category I. E/M services are among the most frequently reported healthcare services, so the AMA chose this order. As with resequenced codes, this arrangement is intended for coding efficiency.


Codes for CPT® Category I fall into six main categories:

Evaluation & Management (99202–99499)

Anesthesia (00100–01999)

Surgery (10021–69990) The code range is further divided into smaller groups by body area or system

Radiology Procedures (70010–79999)

Pathology and Laboratory Procedures (80047–89398)

Medicine Services and Procedures (90281–99607)


CPT® Category II:

Four numbers and the letter F make up Category II codes, which providers can assign in addition to Category I codes. There is no reimbursement associated with Category II codes, unlike Category I codes.

The CPT® code book typically places Category II codes after Category I codes. These codes are listed as follows:

Composite Measures (0001F–0015F)

Patient Management (0500F–0584F)

Patient History (1000F–1505F)

Physical Examination (2000F–2060F)

Diagnostic/Screening Processes or Results (3006F–3776F)

Therapeutic, Preventive, or Other Interventions (4000F–4563F)

Follow-up or Other Outcomes (5005F–5250F)

Patient Safety (6005F–6150F)

Structural Measures (7010F–7025F)

Nonmeasure Code Listing (9001F–9007F)


CPT® Category III:

Category III codes, characterized by four numbers and a letter T, usually follow Category II codes in the code book. Category III codes are temporary codes used to identify new technologies, services, and procedures.

In Category III, temporary codes describing new services and procedures can remain for up to five years. They must meet Category I criteria, including FDA approval, evidence that the procedure is widely practiced, and evidence that it has proven effective. A new Category I code will be assigned to them. Providers can also eliminate Category III codes if they do not use them.

The AMA releases new or updated Category III codes semiannually via its website but publishes the deletions of Category III codes with the full list of temporary codes annually.


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