Comment to CMS: Cancel Multiple Procedure Payment Reduction and Mandate Medical Decision-Making
CMS comment submitted by American Osteopathic Association representatives on AMA RUC September 5, 2018, with tracking number: 1k2-9592-adpg
Starting 2019, the Centers for Medicare & Medicaid Services (CMS) proposes enacting Multiple Procedure Payment Reduction (MPPR) if an evaluation and management (E/M) service and procedure are performed on the same date of service. Citing abuse of modifier 25 Significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service, CMS proposes reducing pay by 50 percent for the lesser value of either a procedure or E/M service. Though MPPR will create a disincentive for abuse, it will also penalize legitimate circumstances where a procedure and separate E/M service are medically necessary. Rather than enact MPPR, abuse may be curtailed by mandating medical decision making (MDM) as an always present key component for E/M documentation.
A Case for MDM
Misuse of modifier 25 can be exemplified by an established patient who receives an injection for knee pain. By documenting history of present illness (HPI) — location: right knee, quality: deep ache, severity: 8/10 — along with vital signs, a problem focused history and problem focused examination satisfy two out of three key component documentation requirements for an E/M service. An auditor can question the medical necessity of the E/M as a separately identifiable service to the injection, but documentation is supported by the guidelines. If MDM were a mandated key component, the provider would need to justify why the E/M was necessary.
Imagine a patient who receives a joint injection (20610) for right knee pain (M25.561), who also has a history of deep venous thrombosis (Z86.718) and currently takes an anticoagulant medication (Z79.01). As a mandatory key component for documentation, MDM would demonstrate how the anticoagulation status was addressed. The provider could document Coumadin was discontinued for three days in advance of the injection and patient/provider shared decision-making justify holding the anticoagulant, as the benefit of the injection outweighed the risks.
A Case Against MPPR
MPPR has the unintended consequence of penalizing providers and impeding care for patients. Imagine the primary care provider who cares for a patient with diabetes mellitus, coronary artery disease, hypertension, and hyperlipidemia who also reports having ear pain with difficulty hearing at a chronic care visit. Without MPPR policy, the provider can immediately identify and remove impacted ear wax with instrumentation. As a gatekeeper, the provider is incentivized to take care of such matters during a chronic care E/M.
Some providers may seem like consistent abusers of modifier 25, but evaluation from an MDM point of view adds clarity. A psychiatrist, for example, may conduct an E/M to manage a patient’s medications and then provide family therapy (98925). Reducing the E/M or separate service by 50 percent undermines comprehensive psychiatric care. Due to an inconvenience of having to return for a separate day of service, our health system may appear to save money because less family therapy will be billed. This policy in practice, however, may result in non-optimal patient care and expose our community to individuals with uncontrolled psychiatric symptoms.
For 2019, simplification of documentation and coding could focus on refinement of MDM. 2016 CPT Workgroup efforts could be re-evaluated and vetted with a consortia effort by CPT, RUC, and coding organizations such as AAPC and AHIMA.
Mandatory documentation of MDM has the potential to curb abuse while allowing for legitimate modifier 25 use, thus underscoring the need for MPPR. Mandatory MDM without MPPR incentivizes providers to care for the multiple needs of patients with documented rationale, evident to all stakeholders.
Please consider an update to E/M guidelines to require MDM as a mandatory key component for all E/M documentation. Also, please consider halting the MPPR proposal.
David F. Hitzeman, D.O., MACOI
Joseph R. Schlecht, D.O., FACOFP
Amy J. Aronsky, D.O., FCCP, FAASM
Michael J. Warner, D.O., CPC, CPCO, CPMA
Doctors Hitzeman, Schlecht, Aronsky, and Warner are, respectively, Delegate, Alternate Delegate, Advisor, and Alternate Advisor representing the American Osteopathic Association (AOA) on the American Medical Association’s (AMA) Specialty Society Relative Value Scale Update Committee (RUC). Dr. Warner is an AAPC National Advisory Board Member.
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