AMA's Summary of the E/M Sections of Medicare's PFS Final Rule
Wednesday, November 7, 2018
Posted by: DCMS
Below is a summary from the American Medical Association on the E/M Sections of Medicare's PFS Final Rule:
Evaluation and Management (E/M) Office Visits and Documentation Guidelines
In the 2019 proposed rule on the Medicare Physician Fee Schedule (PFS), the Center for Medicare and Medicaid Services (CMS) proposed revisions to the E/M documentation guidelines intended to reduce administrative burden on physicians. In addition, CMS proposed coding and payment changes to new and established office visit services. The AMA led the development of a joint comment letter from 170 physician and other health professional organizations calling for CMS to finalize several proposed changes to E/M documentation guidelines for CY2019. The AMA is pleased that CMS is implementing the documentation policies which will significantly reduce administrative burden and allow all physicians to spend more time with their patients. We are also grateful that CMS has acknowledged the work of the AMA’s CPT/RUC Workgroup on E/M and has postponed any coding and payment-related changes for E/M office visit services until CY2021. This delay in implementation will allow the CPT Editorial Panel to consider the Workgroup’s proposal in February of 2019 prior to prompt consideration by the AMA/Specialty Society RVS Update Committee (RUC).
On page 584 of the rule, CMS states:
“We recognize that many commenters, including the AMA, the RUC, and specialties that participate as members in those committees, have stated intentions of the AMA and the CPT Editorial Panel to revisit coding for E/M office/outpatient services in the immediate future. We note that the 2-year delay in implementation will provide the opportunity for us to respond to the work done by the AMA and the CPT Editorial Panel, as well as other stakeholders. We will consider any changes that are made to CPT coding for E/M services, and recommendations regarding appropriate valuation of new or revised codes.”
Removing Restrictions on E/M Coding
CMS finalized several changes to E/M documentation guideline which were strongly supported by the AMA and other members of the Federation:
· The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated.
· Physicians will no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated. In addition,
· Physicians must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the patient.
These changes will take effect 1/1/2019.
The Original Proposal Condensing Office Visit Payment Amounts and Documentation Requirements
In the 2019 proposed rule, CMS proposed to implement a single payment rate for level 2 through level 5 office visits and to reduce documentation requirements for this collapsed payment to that of a level 2 CPT visit code. The Agency proposed to continue to use existing CPT structure for office visit codes 99201-99215, though proposed to change CMS guidelines and only enforce certain aspects of the CPT structure by allowing physicians to choose the method of documentation, among the following options:
1. 1995 or 1997 Evaluation and Management Guidelines for history, physical exam and medical decision making (current framework for documentation)
2. Medical decision making only
3. Physician time spent face-to-face with patients
CMS had also proposed an add-on code to each office visit performed for primary care purposes and an add-on code for specialties with inherently complex E/M visits
CMS relayed that commenters overwhelmingly opposed the Agency’s proposed payment collapse. CMS will not finalize the proposal for CY 2019.
Other Coding/Payment Proposals Related to E/M
The following policies were also opposed by the AMA and will not be implemented by CMS:
· Payment reductions by 50 percent for office visits that occur on the same date as procedures (or a physician in the same group practice). The AMA brought attention to the fact that duplicative resources have already been removed from the underlying procedure through the current valuation process.
· In addition, CMS proposed to no longer allow for podiatry to report CPT codes 99201-99215 and instead would use two proposed G-codes for podiatry office visits. As well as a new prolonged service code that would have been implemented to add-on to any office visit lasting more than 30 minutes beyond the office visit (ie, hour long visits in total).
· Condensed practice expense payment for the E/M office visits, by creating a new indirect practice expense category solely for office visits, overriding the current methodology for these services by treating Office E/M as a separate Medicare Designated Specialty. This change would also have resulted in the exclusion of the indirect practice costs for office visits when deriving every other specialty’s indirect practice expense amount for all other services that they perform, which would have resulted in large changes in payment for many specialties (ie a greater than 10 percent payment reduction for chemotherapy services).
Proposals for CY 2021 and the CPT/RUC Workgroup on E/M
For CY 2021, the Agency conveyed its intention to propose two basic payment rates for office visit services, one for straightforward visits and another for complex visits. In addition, CMS noted their intention to propose add-on codes for primary care and inherently complex specialty E/M visits.
CMS noted they will also consider input from the AMA and the CPT/RUC Workgroup on E/M as well as input from across the medical community. In response to the Medicare Proposed Rule, the Chairs of the AMA CPT Editorial Panel and the AMA/Specialty Society Relative Value Update Committee (RUC) formed the CPT/RUC Workgroup on E/M to:
· Capitalize on the CMS proposal and solicit suggestions feedback on the best coding structure to foster burden reduction, while ensuring appropriate valuation.
· Consider a code change application to be submitted to the CPT Editorial Panel for consideration at their February 7-9, 2019 meeting.
The Workgroup is comprised of 12 experts in both coding and valuation (6 members each from each of the CPT and RUC processes). In addition to the 12 Workgroup members, roughly 300 additional stakeholders from national medical specialty societies, CMS and other health care related organizations have participated.
The Workgroup has expressed their appreciation of the Agency’s efforts to address long standing issues with E/M services and has worked tirelessly over the past several months to establish a long-term, stable CPT coding solution. Listening to CMS and other stakeholder concerns, the Workgroup has worked to build consensus around modernizing the office and outpatient E/M CPT codes to simplify the documentation requirements and better focus code selection around medical decision making and physician time. The Workgroup proposal will be formally reviewed by the national medical specialty societies via the CPT Advisory Committee process. The CPT Editorial Panel will review the proposal, and related comments, at the February 7-9, 2019 meeting.
For more information on the Medicare PFS portion of rule: