AAPC Responds to Proposed E/M Payment Policy Changes
In the Medicare Physician Fee Schedule (MPFS) proposed rule for 2019 payment policies, the Centers for Medicare & Medicaid Services (CMS) introduces radical changes to the way healthcare practitioners would be reimbursed for evaluation and management (E/M) services furnished to their Medicare Part B patients beginning in 2019.
At the crux of the debate that ensued with the release of the proposed rule in July is a provision to change the way Medicare reimburses physicians for CPT® codes 99201-99215 in the office and outpatient settings.
CMS sought public comment on the proposed rule. AAPC submitted comment on behalf of its 175,000+ members.
The comments provided are in response to section I. Evaluation & Management (E/M) Visits.
We agree the Evaluation and Management (E/M) 1995 and 1997 CMS documentation guidelines are administratively burdensome and changes are needed. We applaud CMS for the suggested changes to ease the administrative burden. We agree with the following proposals:
- (i) Eliminating Extra Documentation Requirements for Home Visits: Removal of the requirement to document the medical necessity of a home visit rather than an office visit. Medical necessity for the service should be documented but the decision for the site of service is not needed.
- (ii) Removing Redundancy in E/M Visit Documentation: Allowing ancillary staff or the patient to document all the elements of the history will reduce the redundancy of documentation. The provider can review and update what is required. This will save time and is more consistent with current medical practice.
We have concerns that some of the proposal will increase administrative burden. Without proper vetting, the proposed changes could have unintended consequences.
The specific proposals we are concerned with include:
- Providing Choices in Documentation—Medical Decision-Making, Time or Current Framework
It will be difficult to meet the goal for simplification applying the changes for MDM and time to only the outpatient new and established patients. This will force practitioners to use two different sets of criteria to properly code E/M services. Survey of our membership shows that 40 percent are using E/M categories other than the new and established outpatient services. This will force providers and coders to use different sets of criteria depending on the category of E/M codes used.
If private payers decide not to change the criteria for E/M code selection, it will add an additional level of administrative burden, especially with crossover claims for secondary plans to Medicare. Providers and coders will be forced to code claims using different criteria for different payers.
The timeline for implementation is aggressive. For an efficient roll out, time is needed for training and operational changes to support the proposed changes. The cost will be significant to make the necessary modifications to electronic health record templates and alteration of work flows. During implementation of EHRs, many healthcare systems and practices developed templates to meet the requirements of the 1995 and 1997 documentation guidelines. These framework modifications will lead to additional IT expense and will take time to be programmed.
Providers and coders will require training to code E/M services correctly with the proposed changes. An implementation date in 2020 will allow for proper training and administrative preparedness to comply with the changes to E/M.
We understand the goal for allowing multiple options (current 1995 and 1997, time or MDM) is to reduce implementation difficulties, but the result of so many different options will lead to inconsistency in the E/M level distributions. Providers, in theory, can use three different methods for determining the correct level. This will affect data analytics in the distribution of the E/M levels and resource use for patient care.
Time, as currently defined, is not adequate to identify the complexity of the care provided. Different skill levels of providers can influence the amount of time that is needed to treat the patient. A physician should not be penalized for the ability to treat a complex patient quicker than an inexperienced provider. Face-to-face time does not take into consideration the work done pre- and post-encounter. If time is going to be an option, the face-to-face time definition needs to include the pre- and post-work that adds to the complexity of the delivery of care.
- (iii) Podiatry Visits: We do not agree with separate G codes for podiatry services. This does not allow for the complexity of the visits to be captured. It is unusual that one specialty would be paid under a different fee structure than all other specialties.
- Minimizing Documentation Requirements by Simplifying Payment Amounts: Many healthcare systems and practices use RVUs to monitor staff productivity and utilization of resources. Having only two levels of payment will not allow providers to adequately identify the levels of service required to treat patients.
If the providers are only required to document and provide a level two service, this may lead to patients being seen multiple times to treat conditions, rather than the provider treating all conditions during one encounter. The levels billed should support the complexity of care provided. Collapsing the payment into two levels means a patient with a cold would be reimbursed at the same rate as a COPD exacerbation. The complexity of care and resources required to treat more complex conditions will not be adequately communicated with only two levels of payment. This will also affect the ability to determine true cost under the MIPS program if we only have two payment rates for the new and the established patients.
We propose using the nature of the presenting illness, as defined by CPT®, as part of the criteria for code selection, or requiring MDM as one of the two key components for established patients.
- Recognizing the Resource Costs for Different Types of E/M Visits: The new G codes to identify complexity for primary care services (GPC1X) and specialty services (GCG0X) are not well defined and have a significant chance of being misused. The parameters for using the add-on G codes will need to be better defined. For example, could a specialist also providing primary care services be able to report both add-on G codes? Would the provider be required to have the specialty designation to report the GCG0X?
AAPC has over 175,000 members of which over 124,000 hold the CPC® credential. Members who hold this credential specialize in coding for physician and non-physician practitioners. We are proposing that CMS allow AAPC to pilot the various proposed changes to properly vet the outcome of such a substantial shift in determining the E/M levels. We have over 1,000 medical records for E/M encounters that have been coded using the 1995 and 1997 documentation guidelines. We can have groups of our members code the records using the proposed changes. We will provide data to show the impact the changes will have on code distribution. This exercise will also allow us to provide best practices for implementation.
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