Medicare Proposes Big E/M Changes

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  • September 4, 2018
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Medicare Proposes Big E/M Changes

Be aware of three proposals that would make coding these services easier, but also may negatively affect physician reimbursement.

The Centers for Medicare & Medicaid Services (CMS) has proposed radical changes that, if finalized, would ease the documentation requirements for new and established outpatient visits, while also creating a uniform payment for evaluation and management (E/M) services, regardless of the level of service reported. CMS says it wants you to have a say in the final policy: Here are the facts to help you form an opinion.

CMS Wants to Make Things Easier

In the 2019 Medicare Physician Fee Schedule (MPFS) proposed rule, published in the July 27 Federal Register, CMS presents several policy changes that would affect documentation, coding, and payment for E/M services. In proposing the changes, CMS acknowledged providers’ complaints that current E/M documentation and coding guidelines are burdensome and immaterial to patient care.
We are seeking public comment … to provide practitioners choice in the basis for documenting E/M visits in an effort to allow for documentation alternatives that better reflect the current practice of medicine and to alleviate documentation burden. We are also interested in public comments on practitioners’ ability to avail themselves of these choices with respect to how they would impact clinical workflows, EHR templates, and other aspects of practitioner work. … Our primary goal is to reduce administrative burden so that the practitioner can focus on the patient, and we are interested in commenters’ opinions as to whether our E/M visit proposals would, in fact, support and further this goal.
There are three primary proposals that, if finalized, would apply only to office/outpatient visit CPT® codes (99201-99215).

Proposal 1
Simplify History and Exam Documentation Requirements

One proposed change would:

… simplify the documentation of history and exam for established patients such that, for both of these key components, practitioners would only be required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history.

CMS also proposed:

… for both new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the chief complaint and history that are already entered by ancillary staff or the beneficiary. The practitioner could simply indicate in the medical record that they reviewed and verified this information.

In every case, CMS would expect the provider to continue to document history and exam to the extent required to provide quality care:
Our goal is to allow practitioners more flexibility to exercise greater clinical judgment and discretion in what they document, focusing on what is clinically relevant and medically necessary for the patient. Our expectation is that practitioners would continue to periodically review and assess static or baseline historical information at clinically appropriate intervals.
Providers who wish to document according to either of the existing 1995 or 1997 Documentation Guidelines for Evaluation and Management Services could continue to do so, even if the above proposal is finalized.

Proposal 2
Remove History and Exam from E/M Leveling Decision

Under current E/M documentation guidelines, the history and exam are two of the three required elements, along with medical decision-making (MDM), to be considered when selecting the overall level of E/M service for reporting. CMS proposes to eliminate the history and exam from consideration. As a result, MDM would stand as the sole determinant of E/M service level.
Providers could continue to use time as the determining factor in selecting an E/M service level, if coordination and care comprise the majority of the visit. CMS states in the proposed rule, “For practitioners choosing to support their coding and payment for an E/M visit by documenting the amount of time spent with the patient, we propose to require the practitioner to document the medical necessity of the visit and show the total amount of time spent by the billing practitioner face-to-face with the patient.”
Providers who want to document according to the existing 1995 or 1997 E/M documentation guidelines could continue to do so, even if this proposal is finalized.

Proposal 3 Pay a Single Rate for Level 2-5 E/M Visits

In return for simplified documentation requirements and coding guidelines, CMS proposes streamlined E/M payments. Essentially, there would be two reimbursement levels for new patient visits (99201 and 99202-99205), as shown in Table A, and two reimbursement levels for established patient visits (99211 and 99212-99215), as shown in Table B.
Table A Proposed reimbursement levels for new patient E/M visits

HCPCS Code CY 2018 Non-facility Payment Rate CY 2018 Non-facility Payment Rate under the proposed Methodology
99201 $45 $44
99202 $76 $135
99203 $110
99204 $167
99205 $211

Table B Proposed reimbursement levels for established patient E/M visits

HCPCS Code Current Non-facility Payment Rate Proposed Non-facility Payment Rate
99211 $22 $24
99212 $45 $93
99213 $74
99214 $109
99215 $148

In other words, providers would receive the same reimbursement ($135) for all level 2-5 new patient visits, and for all level 2-5 established patient visits ($93). For those providers who currently report a disproportionate number of low-level E/M services, this proposal could mean a net gain in reimbursement. For those providers who report a disproportionate number of high-level E/M services, this proposal represents a possible net loss.
CMS presents the relaxed documentation and coding requirements (proposals 1 and 2) as a “package deal” with the streamlined payments (proposal 3) — call it the “spoonful of sugar” approach — and touts the overall effect as positive for providers:
If our proposals to simplify the documentation requirements and to pay a single PFS rate for new patient E/M visit levels 2 through 5 and a single rate for established patient E/M visit levels 2 through 5 are finalized, practitioners would still bill the CPT code for whichever level of E/M service they furnished and they would be paid at the single PFS rate. However, we believe that eliminating the distinction in payment between visit levels 2 through 5 will eliminate the need to audit against the visit levels, and therefore, will provide immediate relief from the burden of documentation.

Other Noteworthy E/M Proposals

In addition to the above proposals, CMS also suggests other changes.
Eliminating extra documentation requirements for home visits. CMS states in the proposed rule, “… stakeholders have suggested that whether a visit occurs in the home or the office is best determined by the practitioner and the patient without applying additional rules. We agree, so we are proposing to remove the requirement that the medical record must document the medical necessity of furnishing the visit in the home rather than in the office.”
The adoption of add-on G codes, for use when E/M services dominate the practice or specialty. An add-on G code for primary care will cover resource costs associated with primary care E/M services. A second G code would apply for 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
  • Interventional pain management

The add-on G code would represent the complexity inherent to E/M services in these specialties.
An E/M multiple procedure payment adjustment to account for duplicative resource costs when E/M visits and procedures with global periods are furnished together.
Essentially, this means CMS would reduce payment by 50 percent for E/M services that are submitted with modifier 25 Significant, separately identifiable Evaluation and Management (E/M) by the same physician or other qualified health care professional on the same day of the procedure or other service on the same day as a zero global day procedure.

Make Your Voice Heard

These proposals have serious consequences for providers and staff, both positive (simpler rules surrounding documentation and coding) and negative (possible reduction in overall E/M payments, including an automatic reduction of E/M services billed with certain same-day services). Each proposal deserves your consideration and comment.
To view the 2019 MPFS proposed rule, in full, see the July 27 Federal Register.
To submit your comments regarding these or other CMS proposals, go to, search for ID: CMS-2018-0076-0001, and click the Comment Now! button. Comments are due September 10.

There’s More to Come

Whether CMS follows through with all (or any) of its proposals depends, in part, on stakeholder comments. Whatever the outcome, the decision will be detailed in a final rule. Look to Healthcare Business Monthly and the AAPC Knowledge Center ( for the latest updates when the final rule is released, Fall 2018.
Also read, “Are CPT E/M Codes Changing?”
Whether CMS follows through with all (or any) of its proposals depends, in part, on stakeholder comments. Whatever the outcome, the decision will be detailed in a final rule. Look to Healthcare Business Monthly and the AAPC Knowledge Center for the latest updates when the final rule is released, Fall 2018.

Federal Register, 2019 Medicare Physician Fee Schedule Proposed Rule, July 27, 2018:
Evaluation and Management – CEMC
Evaluation and Management Services:
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John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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