Changes Ahead for CMS E/M Requirements and Reimbursement
Use the next two years to prepare for new documentation guidelines and payment rates.
On Nov. 1, 2018, the Centers for Medicare & Medicaid Services (CMS) finalized in the 2019 Physician Fee Schedule final rule significant changes to documentation requirements and reimbursement for evaluation and management (E/M) office visits (CPT® 99201-99215). The most significant changes are scheduled to take effect on Jan. 1, 2021.
Documentation Requirements Change in 2021
Beginning in 2021, CMS will allow providers flexibility to document their level 2-5 E/M office and outpatient visits using either:
- 1995 or 1997 Documentation Guidelines for Evaluation and Management Services; or
- Medical decision-making (MDM); or
If providers use ’95 or ’97 documentation guidelines or MDM, CMS will require a minimum documentation standard for office/outpatient visit levels 2-4, associated with level 2 visits. This means that the provider will need to document:
(1) A problem-focused history that does not include a review of systems (ROS) or a past, family, or social history (PFSH);
(2) A limited examination of the affected body area or organ system; and
(3) Straightforward MDM measured by minimal problems, data review, and risk (two of these three). Keep in mind that only two of these three elements (history, examination, and MDM) are required for established patient office/outpatient visits.
If the provider documents based on MDM alone, Medicare will require only documentation supporting straightforward MDM, measured by minimal problems, data review, and risk (two of these three).
CMS has not specifically stated the E/M minimum documentation requirements for level 5 office/outpatient visits under the current documentation guidelines, or MDM. The requirements today are:
(1) A comprehensive history that includes an extended history of present illness, complete ROS, and complete PFSH;
(2) A comprehensive examination, which is a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s); and
(3) High complexity MDM measured by extensive problems, extensive data review, and high risk (two of these three). Only two of these three elements (history, examination and/or MDM) are required for established patient office/outpatient visits.
If the provider documents based on time, they will need to document the medical necessity of the visit and the time they personally spent with the patient, face to face. For a level 5 established patient visit (99215), the total time spent on documented counseling and coordination of care must exceed 20 minutes (more than half the reference time of 40 minutes). For a level 5 new patient visit (99205), the documented counseling and coordination of care time must exceed 30 minutes (more than half the reference time of 60 minutes).
CMS has finalized add-on codes to reimburse providers for office/outpatient E/M levels 2-4 visits furnished to patients who require complex care because the “resource costs of the visits they typically perform are not fully captured in the proposed single payment rate for the levels 2 through level 5 office/outpatient visit codes.” The add-on HCPCS Level II codes are:
Primary Care Complexity Code GPC1X Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed healthcare service (Add-on code, list separately in addition to level 2 through 4 office/outpatient evaluation and management visit, new or established)
Non-procedural Specialty Care Complexity Code GPC0X Visit complexity inherent to evaluation and management associated with non-procedural specialty care including endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, interventional pain management, cardiology, nephrology, infectious disease, psychiatry, and pulmonology (Add-on code, list separately in addition to level 2 through 4 office/outpatient evaluation and management visit, new or established)
Extended Visit Code GPRO1: Extended time for evaluation and management serve(s) in the office or other outpatient setting, when the visit requires direct patient contact of 34-69 total face-to-face minutes overall for an existing patient or 38-89 minutes for a new patient (Add-on code, list separately in addition to level 2 through 4 office/outpatient evaluation and management visit, new or established)
Remember: We now may use the following prolonged E/M services code or psychotherapy services code with all office/outpatient E/M visit levels:
+99354 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)
+99355 each additional 30 minutes (List separately in addition to code for prolonged service)
2021 Reimbursement Changes
CMS will make significant changes to the provider reimbursement by consolidating the payments for E/M levels 2-4 into a single rate (one rate for new patients and one for established patients). There will continue to be separate payment rates for level 1 and level 5 new and established patient office/outpatient E/M visit levels. Tables 1 and 2 show how payment rates will change, compared to 2019 CMS non-facility payment rates.
Table 1: New Patient
|E/M code New Patient Visits||Current Non-facility Payment*||Proposed Non-facility Payment *|
Table 2: Established Patient
|E/M Established Patient Visits||Current Non-facility Payment*||Proposed Non-facility Payment*|
*Based on the 2019 CMS non-facility payment rates
CMS calculated each consolidated payment rate by looking at the utilization rate of the office/outpatient E/M services for the last five years (2012-2017) and calculating a rate weighted by the frequency at which they are currently billed. This methodology also was used to arrive at the times for new and established patient office/visit levels 2-4.
The payment rate for each of the new add-on HCPCS Level II codes is:
- Primary Care Complexity Code GPC1X: CMS finalized a work relative value unit (RVU) of 0.25, physician time of 8.25 minutes, no direct practice expense (PE) inputs, and a malpractice (MP) RVU of 0.02.
- Non-procedural Specialty Care Complexity Code GCG0X: CMS finalized a crosswalk to 75 percent of the work and time of CPT® code +90785 Interactive complexity (List separately in addition to the code for primary procedure), which resulted in a work RVU of 0.25, no direct PE inputs, and an MP RVU of 0.02.
- Extended Visit Code GPRO1: The physician time of GPRO1 is finalized as half of the physician time assigned to CPT® code 99354, and half the work RVU of 99354, for a work RVU of 1.17.
In the Interim
At this time, all we can do is wait for further clarification from CMS on the new documentation requirements. Also watch for guidance from the American Medical Association recovery audit contractors, and non-Medicare payers.
CY 2019 Physician Fee Schedule and Quality Payment Program final rule (42 CFR Parts 405, 410, 411, 414, 415, 425 and 495), Nov. 1, 2018: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf
U.S. Department of Health and Human Services CMS “Evaluation and Management Services” guide: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
CMS “E&M Payment Amounts” chart: www.cms.gov/sites/drupal/files/2018-11/11-1-2018%20EM%20Payment%20Chart-Updated.pdf
Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program, as well as changes in the statute from July 27, 2018: www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
- Changes Ahead for CMS E/M Requirements and Reimbursement - February 4, 2019
- CMS Evaluation and Management Office/Outpatient Visit Documentation Changes for 2019 - November 7, 2018