CMS Revises E/M Policy, Promises More Changes

CMS Revises E/M Policy, Promises More Changes

CMS stirs the pot with a final rule to follow through on E/M changes.

Earlier this year, the Centers for Medicare & Medicaid Services (CMS) caused a stir by proposing radical changes to the documentation requirements, coding conventions, and payment of new and established outpatient evaluation and management (E/M) services. With the Nov. 1 release of the Medicare Physician Fee Schedule (MPFS) final rule for calendar year 2019, CMS has shown it will follow through with many of its proposed changes — albeit over a three-year period.

Proposed Changes

CMS’ 2019 MPFS proposed rule, published in the July 27 Federal Register, outlined three primary, proposed changes relative to office/outpatient visit CPT® codes 99201-99215.

Proposal 1: Simplify the history and exam documentation requirements 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.” 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.”

Proposal 2: Eliminate the history and exam from consideration when choosing an E/M service level. Medical decision-making (MDM) would stand as the sole determinant of E/M service level (except when counseling or coordination of care dominated the visit, in which case time could be used as
the primary component to select an E/M service level).

Proposal 3: Providers would receive a flat fee of $135 for all level 2-5 new patient visits, and a flat fee of $93 for all level 2-5 established patient visits.

The proposed rule contains additional suggested changes to include reduced documentation requirements for home visits, reduced reimbursement for E/M services provided on the same day as a procedure, and the creation of add-on G codes to be reported by primary care physicians and certain specialists to compensate for the inherent complexities of specified E/M visits.

In total, CMS argued that reduced administrative burden associated with less stringent documentation requirements would offset any potential loss in reimbursement from the rate changes.

Finalized Changes

As outlined in the 2019 MPFS final rule, for 2019 and 2020 CMS will follow existing coding guidelines and payment structures for all E/M services. That means you should continue to use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services when assigning E/M service levels. There will be no change in how the history and MDM components will be treated when selecting an E/M service level. And Medicare will continue to pay varying amounts for different E/M service levels (i.e., there will be no “single” E/M payment, as previously proposed).

CMS will follow through with a number of important E/M changes in 2019, per the CMS Newsroom fact sheet “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019:”

  • Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
  • For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
  • For new and established patients, E/M office/outpatient visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The practitioner may simply indicate in the medical record that they reviewed and verified this information; and
  • Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

Looking Ahead

The 2019 MPFS final rule lays out further changes to E/M policies that CMS will finalize beginning in 2021. These include:

  • A single payment rate for E/M office/outpatient visit levels 2-4 for established and new patients. Level 5 visits will continue to be paid at a higher rate.
  • Elimination of the history and exam as required components when selecting a service level for E/M office/outpatient visits, levels 2-5. Physicians who wish to do so could continue to use the current 1995 or 1997 E/M documentation guidelines.
  • More flexibility in how E/M office/outpatient levels 2-5 visits are documented. Per CMS, “… when using MDM or current framework to document the visit, we will … apply a minimum supporting documentation standard associated with level 2 visits. For these cases, Medicare would require information to support a level 2 E/M office/outpatient visit code for history, exam and/or medical decision-making.”
  • If time is the controlling component when selecting an E/M service level, providers will be required to document the medical necessity of the visit and that the billing provider personally spent the required time face-to-face with the patient.
  • Implementation of add-on codes for use with level 2-4 E/M office/outpatient visits to describe additional resources inherent to primary care and certain specialized medical care visits.
  • Adoption of a new “extended visit” add-on code to use with level 2-4 E/M office/outpatient visits to account for additional resources when practitioners spend extended time with a patient.

Although implementation of these steps is assumed, CMS “intends to engage in further discussions with the public to potentially further refine the policies for CY 2021.”

Off the Table

The final rule lays to rest several proposals that CMS says it will not adopt. These include reduced payment when an E/M office/outpatient visit is furnished on the same day as a procedure and separate codes and payment for pediatric E/M visits.

AAPC Will Bring You More

The 2019 MPFS final rule was released as this issue of Healthcare Business Monthly was going to press. Keep an eye on future issues, as well as AAPC’s Knowledge Center for more information about the final rule, including further details about new policies regarding new and established patient office/outpatient visit codes 99201-99215.


Resources

Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019 at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf

CMS Newsroom, Fact Sheet, “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019” at: www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year

1995 or 1997 Documentation Guidelines for Evaluation and Management Services:

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

Evaluation and Management – CEMC

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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