Revenue Cycle Insider

CMS seems to move in opposite directions, but the changes all affect reimbursement more than code selection.

In the recently released calendar year (CY) Medicare Physician Fee Schedule (MPFS) proposed rule, “Medicare and Medicaid Programs; CY 2027 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program, the Centers for Medicare & Medicaid Services (CMS) is proposing policy changes that continue to prioritize longitudinal care, among changes impacting other aspects of care. The proposed changes may be a relationship and reimbursement boon to some primary care providers, and a possibly less profitable adjustment for some specialists, as payments for certain evaluation and management (E/M) services face possible changes to reduce what CMS claims are overlapping payments.

Practices should consider how the proposed changes may affect their reporting, documentation, and compliance, particularly as the changes affect payment more than coding criteria/selection.

Note the Proposed Changes

CMS is proposing to delete the HCPCS code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (add-on code, list separately in addition to home or residence or office/outpatient evaluation and management service, new or established)) and establish a new modifier, with adjusted payments, to report qualifying E/M services. The G2211 code hasn’t been around very long, having been established as an add-on code in the 2021 MPFS, and available for payment since Jan. 1, 2024.

CMS says that the new, proposed modifier replacing G2211 would increase payment by 16 percent, rather than a flat amount. This 16 percent increase is a percentage of the payment for the underlying E/M code, not a 16 percent increase to the entire claim.

The actual dollar impact would vary because it would scale with the payment for the underlying E/M level. Higher-level office visits would receive a larger dollar increase than lower-level visits. CMS specifically notes that the goal is to maintain “an equal percentage increase across all levels of E/M codes.”

CMS also announced a proposal for a second modifier that accountable care organization (ACO) participants could use, which would increase payment by 32 percent. CMS says these changes will support fair reimbursement for the additional resources required in maintaining longer-term care relationships, including care coordination and quality reporting, as well as accountability for the total cost of care.

Additionally, CMS is proposing to reduce the payment for separately identifiable office/outpatient E/M visits, which are often reported with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and provided on the same day as a procedure within a global period.

CMS proposes paying the most expensive service, either the surgical service or the E/M visit, at 100 percent and any additional surgical procedures or E/M visits furnished on the same day by the same physician or by a physician in the same practice at 50 percent. In its MPFS 2027 Fact Sheet, CMS reasons “that there are efficiencies when the same physician (or a physician in the same group practice) provides an E/M service for the same patient in conjunction with a procedure with a global period and that we are likely duplicating payment under the current payment methodology. The current proposal would address that overvaluation.”

Here is a conceptual, informal example: If a practice currently bills a procedure and receives $300 in reimbursement, as well as an E/M service for which it receives $150 in reimbursement, it would mean $450 for the combination. If the proposed changes are finalized, the payment for the same situation might mean receiving 100 percent reimbursement for the most expensive procedure ($300) and 50 percent of the E/M service ($75) for a total payment of $375.

Even if practices are reporting separately identifiable services correctly, their reimbursement could be reduced if these changes are finalized.

Ask These Questions in Your Practice Preparations

Practices preparing for these changes, if finalized, may have questions about how to code these E/M visits. While CMS isn’t proposing new selection criteria for E/M coding, there are operational and compliance questions about implementing the changes, should they become finalized. CMS seems to be trying to figure out ways to navigate payment rather than coding, but practices may have to adjust their coding to keep up.

Practices will want to know which patients and visits qualify for these modifiers, whether practices should monitor these modifier usage rates, how documentation can illustrate and support longitudinal care relationships, and whether any electronic health record (EHR) system templates need to be revised.

Regarding the proposed payment changes for separately identifiable services within a global period, practices should evaluate their current modifier 25 usage patterns, and how they document and support modifier 25 reporting.

Know Your Options for Public Comment

Stakeholders concerned with any of the proposed changes have time to make public comment, and, in the past, CMS has been receptive — especially if comments include specific information about how practices will be impacted, like specialty-specific examples, analyses of financial impact, and operational or patient access challenges. For example, practices may be concerned about having to schedule more appointments across different days to achieve the same level of reimbursement for separately identifiable services and make an argument that the proposed changes would impact patient care access. Stakeholders can submit comments electronically until September 14.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC