Urology Coding Alert

Revamped E/M codes would be a big change.

The Medicare Physician Fee Schedule (MPFS) for CY 2019 was first released on July 12, 2018, and published officially in the Federal Register on July 27, 2018. Read on for some top-level highlights – plus expected E/M changes that will affect every physician practice.

Biggest Changes Will Come From E/M

The biggest surprise in the proposed MPFS for CY 2019 is that the rule includes a long-promised revamp of evaluation and management (E/M) codes.

Background: CMS has been compiling stakeholder feedback on overhauling E/M services for a while now, but the suggested changes go far beyond dropping one of the three documentation requirements. In fact, the proposed MPFS pinpoints “a number of coding and payment changes to reduce administrative burden and improve payment accuracy” that CMS would like to implement in 2019, notes CMS’s MPFS fact sheet.

Those “historic” E/M documentation propositions that CMS presents include:

• Use medical decision-making or time for outpatient E/M versus the current guidelines.
• Give physicians the option of using time as a factor even if counseling or care coordination are part of the medical equation.
• Put re-documenting aside and let providers “focus their documentation on what has changed since the last visit or on pertinent items that have not changed.”
• Give practitioners the option of accepting data plugged in by staff instead of timely re-entering the same data themselves.

“CMS says this would simplify, streamline and offer flexibility in documentation requirements for these types of visits, which make up for 40 percent of allowed charges under the PFS,” indicates law firm Hall Render in analysis on its Health Law News blog. “The proposed rule changes the current system of four sets of documentation requirements and reduces it to a single set of documentation requirements.”

Important:  Over the years, CMS has received public commentary that suggests “E/M codes need substantial updating and revaluation to reflect changes in the practice of medicine,” states the MPFS proposal. After numerous listening sessions this past spring, CMS designed a plan to rework the E/M, keeping EHRs in mind for the documentation standards, but also to create “new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services,” informs the fact sheet.

What this means: “Some specialties will likely suffer more than others with the relative value units (RVUs) of these much-used E/M codes set at a single payment rate,’ the MPFS says. So instead of varying rates for the codes as their complexity increases, CMS advises in the proposal that the payments would be the same.

For example, Medicare pay for E/M codes 99212 through 99215 would be straight across the board at $93 while 99202-99205 would all equal $135, the MPFS shows in Tables 19 and 20. A “multiple procedure payment adjustment” in addition to various “HCPCS G-code add-ons” and other factors would impact the eventual end payment, with some clinicians slated for financial gain or losses depending on the specialty, the MPFS suggests.

“If these proposals are confirmed, on January 1, 2019, podiatry and dermatology will see substantial increases of E/M payments of 12 percent to 7 percent respectfully, with endocrinology seeing a decrease of 10 percent in their E/M payments,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. “Fortunately for us, urology will only see minimal payment changes.”

Technology Focus Is No Surprise

Every aspect of the proposed rule promotes CMS’s heightened focus on utilizing health IT to enhance care and cut costs while decreasing clinicians’ workloads. Some non-E/M high points from the rule include:

• Conversion factor:  The national conversion factor will increase, but not by much. It shows about at a 0.17 percent increase to account for inflation and slated to go from $35.99 to $36.05.
• Quality program: The MPFS proposals include transition updates, cost and quality scoring changes, threshold guidance, small practice bonus downgrades, and several tech-friendly policies that bring Promoting Interoperability (PI) to center of MIPS.
• Telehealth: You’ll see two more codes for telehealth — HCPCS codes G0513 and G0514 (Prolonged preventive service(s)…) — as well as 2018 Bipartisan Budget Act telehealth requirements for end-stage renal disease (ESRD).
• Virtual care: Payment increases for the use of audio and visual communication that “leverage technologies.”
• Part B medications: The proposed rule wants to see beneficiaries get their meds for less. “Effective January 1, 2019, [wholesale acquisition cost] WAC-based payments for new Part B drugs during the period first quarter of sales when ASP is unavailable, the drug payment add-on would be 3 percent in place of the 6 percent add-on that is currently being used,” the fact sheet advises.
• Medicare Advantage: MIPS requirements would be waived for Medicare Advantage providers interested in participating in the QPP. The program will be called the “Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration” and is for clinicians whose “arrangements are similar to Advanced APMs,” explains the fact sheet.

“Today’s reforms proposed by CMS bring us one step closer to a modern healthcare system that delivers better care for Americans at a lower cost,” said Alex Azar, HHS Secretary in a press statement. “Such a system requires empowering American patients by giving them price and quality transparency and control over their own interoperable health records, goals supported by CMS’s proposals.

But there’s more: Other updates impact clinical lab and ambulance fee schedule changes, therapy services, practice expenses (PEs), price transparency, new procedure codes and code revaluations, the Stark Law, and more.

“Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care,” said CMS Administrator Seema Verma in a press release on the MPFS. “This Administration has listened and is taking action.”

She also stressed, “The proposed changes to the Physician Fee Schedule and Quality Payment Program address those problems head-on, by streamlining documentation requirements to focus on patient care and by modernizing payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need.”

Resource: For a closer look at the MPFS proposed rule for CY 2019, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf.