Analysis: AMA Responds to E/M Proposal
The American Medical Association (AMA) sent a letter to the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma on Aug. 27, 2018, with signatures from medical societies with comments on the CMS proposal for the Patients Over Paperwork initiative.
AMA Loves Paperwork Reduction
In the letter, the AMA says that they support CMS’ initiative to reduce paperwork and administrative burdens for physicians and other healthcare professionals so that more time can be focused on the patients. The letter also brought up that not only do the current guidelines, which lead to excessive documentation, cause the patient to be shortchanged, they also lead to “note bloat,” with excessive, redundant, and irrelevant information, making it difficult to quickly find the important information about the patient’s illness and most recent test results to best determine an assessment and plan for that patient. The AMA and those who signed the letter feel that the proposed rule would help to reduce these problems significantly.
They also ask for the following three changes:
- Changing the required patient’s history to focus only on the interval history since the previous visit
- Eliminate the requirement for providers to re-document information in the chart that has already been documented by practice staff or the patient
- Removing the need to justify providing a home visit instead of an office visit
What Does the AMA Want?
I find the first issue interesting, since I teach providers to document interval histories for established patients. The electronic health record and its copy and paste function have exploded the presence of redundant information. If the provider just documented that the prior history of [date] had been reviewed and what has changed, an interval history is captured and the current rules have been meant. The first bullet almost shows that those writing and signing on to this letter do not fully understand documentation of history for established patients.
The second bullet makes sense. If ancillary staff captures the history of present illness (HPI), the provider should be able to just indicate they read and agree with the HPI without having to document the same information again.
The third bullet seems to say that providers wish CMS and other payers trust their decision making when the provider determines that the patient needs a home visit, therefore not requiring it to be justified in writing in the note.
I find it interesting that the comments focused on the history when the proposal from CMS was looking at eliminating the history and exam from determining the visit level, depending entirely on the medical necessity of the presenting problem(s).
The letter went on to address the collapsing of the payment rates from the current eight different payment levels for new and established office patient visits to one for new patients and one for established patients. The letter indicated that the AMA and supporters object to this payment structure because it could financially punish providers in specialties that treat the sickest patients. Stakeholders also believe it could penalize those who provide comprehensive primary care, which will ultimately jeopardize patients’ access to care.
AMA Says No
The AMA also asked CMS to not implement the multiple service payment reduction (when modifier 25 is used). They said that the valuations of the codes have already factored in the concept of multiple services on the same day.
The letter concludes with the suggestion to create a workgroup of physicians and other healthcare professionals with deep expertise in defining and valuing codes and who also use the office visit codes to describe and bill for services provided to Medicare patients. This workgroup’s objective would be to analyze evaluation and management services coding and payment issues and arrive at concrete solutions that can be proposed to CMS in time for implementation by 2020.