CMS Proposes a Single E/M Payment, Streamlined Doc Requirements

CMS Proposes a Single E/M Payment, Streamlined Doc Requirements

The Federal Register scheduled for publication on July 27, 2018 will include a proposal for a single E/M payment for new outpatient services, and a different single E/M payment for established outpatient E/M services, regardless of the E/M level submitted. This is one of several Centers for Medicare & Medicaid Services’ (CMS) proposals to streamline E/M documentation requirements, as part of the 2019 physician fee schedule rule.

How Much is the Proposed Single E/M Payment?

The proposal would create a single reimbursement of $135 for 99202-99205, no matter the level of service is submitted. The current reimbursement (2018, non-geographically adjusted, non-facility) is $109.80 for 99203 and $167.40 for 99204’s. Under this proposal, 99201 would be paid a separate rate that is approximately the same as the current rate.

This single proposed rate for 99212-99215 is $93. Current payment is $74.16 for 99213 and $109.44 for 99214 (2018, non-geographically adjusted, non-facility). The proposed rate compares favorably for these service levels, but note that the current payment for 99215 is $147.60, which is well above the proposed single payment rate.

Along with the single payment, CMS is proposing streamlined documentation requirements. There are a several proposals on the table, one of which would eliminate the 1995 and 1997 documentation guidelines and rely solely on medical decision-making (MDM). The reasoning behind the proposal is that the current documentation guidelines are an exceptional administrative burden.

Other proposed alternatives are the use time as a deciding factor for E/M level, or allowing providers to continue to use the ’95 or ’97 guidelines, should they wish to do so. The proposed rule contends, “This would allow different practitioners in different specialties to choose to document the factor(s) that matter most given the nature of their clinical practice.”

CMS is also considering the adoption of add-on G codes—one for primary care providers and one for specialists—for use when E/M services are dominate within the practice or specialty. The add-on G code for primary care will account for inherent resource costs associated with furnishing primary care E/M services. The G code for specialists will apply to those specialties in which E/M services make up a large percentage of overall charges, including: endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, and interventional pain management. The add-on G code designed for specialty professionals is supposed to represent the complexity inherent to E/M services in these specialties.

Evaluation and Management – CEMC

CMS is also considering reducing the payment for E/M services that are submitted with a 25 modifier by 50 percent, when an E/M service is performed on the same day as a zero global day procedure. The rule makes no mention of payment reductions for E/M services submitted with modifier 25 in addition to same day procedures with a 10-day or 90-day global period.

Barbara Cobuzzi

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.
Barbara Cobuzzi

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Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

3 Responses to “CMS Proposes a Single E/M Payment, Streamlined Doc Requirements”

  1. Michael Warner, DO, CPC, CPCO, CPMA says:

    Dear Barbara,
    There is a big difference in work value between 99202 (0.93) vs 99205 (3.17), and also 99212 (0.48) vs 99215 (2.11). Per AAPC’s RVU calculator, you can see the differences in value assigned to these codes: 99202 (RVU = 0.93), 99203 (1.42), 99204 (2.43), 99205 (3.17), 99212 (0.48), 99213 (0.97), 99214 (1.50), 99215 (2.11).
    I fear the new proposal overlooks human nature. Imagine hiring someone to clean your house and you pay the same amount of money whether the person changes bed linens and washes the sheets, wipes surfaces, vacuums carpets, mops floors – or simply wipes off the countertops in the kitchen. For the same amount of pay, it stands to reason many workers will wipe off the counter and run to the next job site.
    If the same scenario plays out in healthcare, this proposal may undermine complex and high risk care. The proposed set fee for all four levels rewards minimal work and punishes hard work. What is your impression of the proposal to pay the same for level 2 through level 5 care?
    Thank you for your timely and important article.
    Mike

  2. Barbara Cobuzzi says:

    Mike,

    I totally agree. .Medicare (and perhaps other insurances may follow) is basically saying that there is one fee for an EM service and it is up to the provider to do what is medically necessary. Hopefully providers will have integrity and dedication to their patents to do the correct amount of work requred as dictated by the presenting problem. They won’t have the burden of documenting huge amounts to support that high level em service because the “level” won’t matter. An office visit (generic) will just be worth $93 no matter how much work is needed to be done. Remember that primary providers and some specalstss will have the add on G codes to get a very little bit more

  3. Barbara Cobuzzi says:

    Mike,

    I totally agree. .Medicare (and perhaps other insurances may follow) is basically saying that there is one fee for an EM service and it is up to the provider to do what is medically necessary. Hopefully providers will have integrity and dedication to their patents to do the correct amount of work requred as dictated by the presenting problem. They won’t have the burden of documenting huge amounts to support that high level em service because the “level” won’t matter. An office visit (generic) will just be worth $93 no matter how much work is needed to be done. Remember that primary providers and some specalstss will have the add on G codes to get a very little bit more

    Barbara

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