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The Physician Fee Schedule for 2020 brought better news this year, as neurologists and other cognitive specialists will be able to bill for more of their time for E/M codes, among other changes.

What a difference a year makes!

In the summer of 2018, the Centers for Medicare and Medicaid Services (CMS) issued proposed changes to the Medicare Physician Fee Schedule that would have collapsed the existing five-tier Evaluation and Management (E/M) code structure, with blended payment rates for office and outpatient visits billed at the second through fifth levels.

Clinicians practicing in a number of specialties stood to lose reimbursement dollars under the proposal, but neurologists would have taken one of the worst hits.

A study published in JAMA Neurology calculated that neurologists would lose a median of $3,226 annually and cardiologists would lose a median of $3,203, while dermatologists and orthopedists would get an annual median boost of $16,655 and $6,239, respectively.

A veritable blizzard of comments and advocacy from neurologists and other physicians practicing in cognitively-focused specialtiesmuch of it led by the AANconvinced the CMS to delay and re-evaluate their proposal. And then, on July 29, 2019, the agency unveiled a new plan, designed to align its E/M coding with changes laid out by the American Medical Association (AMA)'s CPT Editorial Panel for office/outpatient E/M visits.

The Final Rule, officially released on November 1 for implementation in 2021, maintains the existing five levels of coding for established patients and reduces the number of levels for new patients to four, by eliminating the code 99201.

The proposed changes also allow clinicians to choose E/M visit levels using either medical decision-making or time. CMS also proposed the addition of an add-on code (15-minute increment) for prolonged service time, and a separate add-on code to recognize the complexity inherent to E/M services that are part of ongoing care related to a patient's single, serious, or complex chronic condition.

What does that mean for practicing neurologists? It's a swing of $150 million a year annually in the positive direction, Daniel Spirn, AAN's senior regulatory counsel told Neurology Today. Documentation guidelines have also been simplified, news that every practicing neurologist will likely welcome. This really is one of our biggest advocacy wins ever, he said.

It's a major landmark success, agrees Brad C. Klein, MD, MBA, FAAN, a neurologist in private practice at Abington Neurological Associates in Willow Grove, Pennsylvania and clinical associate professor of neurology at Thomas Jefferson University who is a member of the AAN Board of Directors and chair of the Medical Economics and Practice Committee.

For years it's felt like our reimbursement for cognitive care has continued to drop at the expense of other more procedural specialties, and this is a major turnaround. That face-to-face time we spend with patients can really change a person's life.

Last year's proposal posed a major threat to neurologists' time with patients, said Kara Stavros, MD, a neurologist at Rhode Island Hospital and assistant professor of neurology at The Warren Alpert Medical School of Brown University, and a member of the AAN Advocacy Committee.

E/M services are so important for what we do as neurologiststhe time we spend with patients to make the diagnosis, counsel, and manage the condition. For example, I'm a neuromuscular specialist treating patients with very complex conditions like muscular dystrophy or ALS, and if I can't spend an appropriate amount of time with them, their care will suffer. It's gratifying to see that the intensity of what we do is valued by CMS, and that they recognize the importance of the time we spend with our patients.

Advocacy by the AAN and its members across the country played a critical role in CMS' about-face, Spirn says. We quickly and aggressively responded to last year's proposed fee schedule. In the last half of 2018 alone, we had five different meetings with staffers at the Department of Health and Human Services and 54 meetings on Capitol Hill, all pushing CMS not to collapse the E/M codes. And over 700 AAN members contacted their Members of Congress in response to our advocacy alerts.

A January 2019 letter to the AAN from Deputy Secretary of Health and Human Services Eric Hargan praised the organization's efforts, saying We appreciated the input of Dr. [Marc] Raphaelson [a member of the AAN Health Policy Subcommittee and AAN RVS Update Committee (RUC) Representative] and Mr. Spirn, who highlighted for us the challenges faced by neurologists in today's reimbursement environment and the advantages of using time as a variable in coding E&M visits.

The Academy also received the American Association of Medical Society Executives (AAMSE) Profiles of Excellence award for its regulatory advocacy pushing back against the proposed changes. This truly was a full court press and the AAN pulled it off, said the AAMSE award judge.

And the AAN didn't rest on its laurels after the 2018 success. In March 2019, AAN members and staff met with CMS leadership, stating the case for the value of E/M services and their critical importance to neurologists. The Academy also participated in all the meetings of the AMA's E/M workgroup, setting the groundwork for what CMS ultimately proposed and finalized this year in the November Final Rule for 2021 implementation.

Even after the proposal came out in July, we have been actively involved in making sure that CMS would finalize these very positive reimbursement trends for neurology, Spirn said.

These efforts included a 41-page comment letter to CMS and an editorial from AAN President James C. Stevens, MD, FAAN, and the president of the American College of Rheumatology published in Fierce Healthcare, both supplementing the AAN's previous meetings with CMS on the subject. In the end, CMS did finalize the proposal as we wanted to see it, Spirn said.

Although the rule is titled 2020 Medicare Physician Fee Schedule, that name is misleadingthe new codes won't go into effect until January 1, 2021.

Dr. Klein said that the AAN will offer a host of educational programming over the next year to help members prepare for the new fee schedule, beginning with a webinar on December 12 and including extensive offerings at the 2020 Annual Meeting in Toronto in April. (See the website at http://www.aan.com for further details and updates.)

Not all the news about reimbursement for next year is good. CMS has also established a new coding structure for reporting long-term EEG monitoring services beginning in 2020 that likely will have a negative financial impact on some neurologists.

These changes had been in the works since November 2016, when CMS identified CPT Code 95951 (long-term EEG monitoring with video) as a high-volume service, as growth in Medicare claims exceeded 10,000 and increased by at least 100% from 2009 -2014.

The problem with this code is that it was really intended for a monitored service in the inpatient setting, but the description is left open to interpretation such that it could be done in an unattended outpatient setting, not requiring much expense, and generate a lot of income, said Dr. Klein. In short, CMS felt it was being reimbursed too much.

Among the changes in the revision:

These changes will lead to a significant decrease in reimbursement for some neurologists and institutions, particularly given that physician work RVUs (wRVUs) are lower than for the current codes, reflecting efficiencies that have developed in EEG monitoring over the past two decades.

But it could have been worse. Medicare's original proposal rejected the RVU valuations for four of the ten physician work proposed by the AMA's RVS Update Committee (RUC) based on surveys of neurologists across the country.

In response, the AAN engaged in a major advocacy effort in partnership with the American Epilepsy Society, the National Association of Epilepsy Centers, and the American Clinical Neurophysiology Society, to educate Medicare that the devaluation of these four RUC values was not fair or accurate, said Dr. Klein. Ultimately, CMS agreed to bring those code values back up to the level recommended by the RUC. Even though this represents a financial loss to neurologists, there were a lot of steps along the way where it could have been a lot worse.

In another new wrinkle, Medicare elected not to establish national values for the technical component codes. Instead, rates will be set by each Medicare Administrative Contractor (MAC), for their geographic jurisdiction. Private health care insurers will also set their own payment rates and are subject to independent negotiations with health care providers, as is the case with any existing service.

This is something physicians rarely considered, said Dr. Klein. Previously, we always had a global value for the work involved in EEG services. Now, we will see a value of zero for the technical components. To find out our payment rates for these codes, we have to take the extra step and reach out to our local MACs, and these rates will be non-negotiable. However, we will also have to reach out to our commercial payers, where these rates may be up for discussion. Regardless, these changes are going to have an impact on decisions like buying new equipment, staffing, and what services will be provided. Whether in an academic center or private practice, providers will need to understand these nuances to make the right decisions for their practice.

Unlike the physician fee schedule, the EEG changes officially go into effect on January 1, 2020. We are working to help our members who do a lot of EEG work transition to the new codes, said Elaine C. Jones, MD, FAAN, a member of the AAN's Board of Directors who has chaired the AAN's Government Relations Committee and currently chairs the Coding and Payment Policy Subcommittee.

We will also be working with the insurers on the payment decisions that are being pushed back to the regional MAC carriers regarding what is appropriate reimbursement and monitoring how that rolls out going forward as well.

Dr. Jones also urged members to pay attention to changes in chronic care management codes, which include new and enhanced care management services and even two new codes for Principal Care Management.

When the original codes initially came out, they were rather difficult for neurologists to use because of excessive documentation requirements, and because it was unclear whether or not they could be billed by multiple providerssuch as discharge monitoring and transitions of care for a patient who has visits with both a primary care provider and a neurologist, she says.

Now, I think these changes mean we will be able to incorporate them a little more easily. We're already doing this kind of care management now, and it's less difficult to bill for than it was, so this represents revenue we can start picking up.

This is a real opportunity for those who can take advantage of these codes, said Joel M. Kaufman, MD, FAAN, chair of the Care Delivery Subcommittee of the AAN's Medical Economics & Practice Committee.

It's true that procedures like long-term EEG monitoring have been an incredibly useful tool in neurology, but with these changes, there's an opportunity to balance the need to do procedures with the importance of managing patients with chronic conditions.

Overall, said Spirn, these developments underscore the AAN's growing role as a thought leader in healthcare policy. There used to be a time when we could only hope CMS and HHS leaders would meet with us. Now, we often meet several times a year, and agency leadership takes time to write us letters thanking us for our feedback and involvement. That's an incredible shift in how they see the AANas a resource they can go to when making policy.

That shift can be credited to the AAN's approach to advocacy. It's not about protecting the physicians' pocketbooks or making more money; it's about the right thing for the patients, Dr. Jones said.

We feel that we do better by making our care better and improving our patients lives. That's what the AAN focuses on, and as a result, it has really become recognized as a fair and thoughtful voice out there for the right way to do health care.

Dr. Klein has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Allergan, Amgen, Biohaven, Depomed/Assertio, Eli Lilly and Company, Teva, US WorldMeds, Promius, Eagalet, and the AAN. Dr. Klein has received compensation for serving on the board of directors of Appsbydocs, LLC, and Makers of P-Cog. Dr. Klein has received research support from Allergan, Alder Pharmaceuticals, and Eli Lilly and Company. Dr. Jones has been reimbursed for travel and lectures for MER, a CME company.

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