E/M: 2019 Proposed Physician Fee Schedule – Next Steps

 
Proposed changes in the Medicare Physician Fee Schedule (MPFS) for 2019 will change proposed reimbursement single evaluation and management (E/M) rates. Here’s a way for medical coders to see how much the new routes may affect your workplace’s reimbursement. This exercise will also help you determine what to share with CMS during the comment period.
E/M: Practice Analytics
Look at your full year for 2017 data or the first 6 months in 2018 of new patient and established outpatient E/M revenue and compare the same revenue to a single new patient payment of $135 and a single established patient payment of $93 for the same volume for that 6 months. See if the practice comes up ahead or behind with the new proposed single rates.
Then look at all of the instances when a modifier 25 was used with an established outpatient E/M and a zero global day procedure was also billed. Cut the $93 fee in half, to $46.50 and calculate what revenue will be lost and how the practice’s 6-month revenue will fall due to the reduction of fees for 25 modified established outpatient E/M services when performed with zero global day procedures. Does this proposed change in reimbursement for the 25 modified established outpatient E/M services along with the proposed single rate for new and established outpatient E/M patient services cause your practice to project to be ahead in 2019 or behind in 2019?
E/M: Feedback to CMS on the Proposed Rule
Send in the results from your analytics to your specialty so that they can collect this information and include it in their comments to the proposed changes for the 2019 Medicare Fee Schedule. You can also make comments to the proposed 2019 fee schedule yourself, adding to number of organizations providing feedback to CMS on the effect of their proposals.
E/M: Change in Documentation Focus to Measure Level
Measuring the E/M level based on Medical Decision Making will put more weight on the documentation on the Assessment and Plan in the chart. The practice should look at what is currently being documented by each provider in the practice and evaluate what needs to be beefed up so that the MDM sufficiently demonstrates the complexity of the encounter. So far, template development has concentrated on the history and exam. These changes may mean the development of templates to support the MDM in the Assessment and Plan section of the E/M documentation.
Keep in mind that MDM is not necessarily required for the determination of the level of an established outpatient E/M since only 2 of 3 components are required. This new change in documentation requirements for E/M services, relying only on MDM will shift the documentation focus on many charts. It will require a different orientation and the development of tools (templates) to support the provider within the MDM section of the chart.
E/M:  Auditing
Currently, a chart may be measured against the 1995 and 1997 guidelines and the provider given credit for whichever guideline gives the best results for the encounter. This means once a chart is audited against the 1995 guidelines, small variances in the history and large changes in the exam need to be made to measure the documentation against the 1997 guidelines so that the audit can measure against both guideline sets and determine which results provides the highest E/M level, within the context of medical necessity of the presenting problem.
The new proposals include offering the 1995 guidelines, the 1997 guidelines, using only MDM or using time, whichever best fits the services of the practice. Having four possible guidelines to audit a chart against has the potential of consuming much more time for audits. The reason for the single rate and moving to MDM for determining the E/M level is to reduce the administrative burden. However, if there are still 4 possible guidelines against which a chart may be audited, although the administrative burden for the documentation of the encounter may be reduced, the administrative burden for compliance activities are actually being increased
Include this within your comments to the proposed rule to CMS and the federal rule.
 
https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
 

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Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, COC, CENTC, CPC-P, CPC-I, CPCO, CMCS, is CEO of CRN Healthcare Solutions and formerly owned a medical billing company. Cobuzzi is a subject matter expert in otolaryngology coding. She provides litigation support as an expert witness for providers and payers and often presents for many local and national organizations. She is also a consulting editor for AAPC’s Otolaryngology Coding Alert newsletter. In 1999, Cobuzzi was named AAPC’s Networker of the Year, and she is a past member of the National Advisory Board. She is one of four founding members of the Monmouth/Ocean, N.J., local chapter and is still active with the chapter.

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