The Centers for Medicare & Medicaid Services (CMS) is proposing three new HCPCS Level II add-on codes to be used specifically with evaluation and management (E/M) codes, which would also be revised to create a single rate of $93 for established patients (99212-99215) and a single rate of $135 for new patients (99202-99205).

The add-on codes are designed to provide for an additional payment to primary care providers, as well as specialists whose use of E/M codes dominates the specialty.

These changes would, if finalized, apply to Medicare Part B only; Medicare Advantage has its own rules so, unless private insurance companies that offer Medicare Advantage plans adopt the proposed Medicare rules for payment of E/M services, they will apply to Medicare Part B patients only.  And should non-Medicare insurance companies decide to adopt these new reimbursement proposals, as outlined by CMS, there is no guarantee that the non-Medicare payers will adopt the proposed Medicare Part B add-on codes (that are not Level 1 CPT® codes).

Add-on Code GPC1X

HCPCS Level II code GPC1X Visit complexity inherit to evaluation and management associated with primary medical care would be added to established office/outpatient CPT® codes . This code is designed to capture the additional resources that a primary care practice expends in caring for patients in a primary care environment beyond the average E/M visit.

CMS says that they expect this add-on code to be billed for every primary care established patient. CMS also says that the add-on code is not reimbursing for services that could otherwise be reimbursed by a more specific code, and CMS is only reimbursing for additional face-to-face services provided by the primary care provider.

Primary care includes family practice, general medicine, and internal medicine. CMS is accepting comments as to whether “other specialties” who are acting in the role of primary care (e.g., OB/GYN, geriatrics, cardiology) might also be eligible for this add-on code.

Add-on Code GCG0X

The second add-on code described in the proposed rule is HCPCS Level II GCG0X Visit complexity inherent to E/M associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/GYN, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care. These specialties were included with GCG0X because not all of the services include surgical interventions, and the encounters demonstrate increased complexity.

Add-on Code GPR01

Although CPT® has add-on codes for prolonged services, proposed HCPCS Level II code GPR01 Prolonged Evaluation and Management or psychotherapy service beyond the typical service time of the primary procedure would reflect only 30 minutes of prolonged services, as opposed to the one hour of prolonged services that the current CPT® codes require. However, like the current CPT® codes for prolonged services, this add-on code requires direct face-to-face time between the provider and the patient.

This code can be used with the primary care GPC1X and specialty complexity of care GCG0X. This means that an encounter with prolonged services documented would be coded and billed with an E/M service, with the add-on for primary care or specialty complexity of care, and the prolonged service add-on code (three codes, total).