Just When You Think You’ve Heard It All: CMS’s Proposal for an E/M Makeover

Unless you’ve been living in a cave, you’ve probably heard about the recently released proposal by the Centers for Medicare and Medicaid Services (CMS) for changes to the Evaluation and Management (E/M) coding guidelines. In the press release dated July 12, 2018, CMS stated, “Today’s proposals deliver on the pledge to put patients over paperwork by enabling doctors to spend more time with their patients.” Clearly, CMS has heard physician complaints over the years as electronic medical records and increasing government regulations have added burdensome and complex requirements that take away from the time to deliver good patient care. Now, CMS is attempting to listen and respond with several ideas that may lessen the frustrations. Considering the last sweeping changes to E/M codes happened over 20 years ago, you have to give CMS credit for trying!

One key proposal includes bundling into a single payment office new patient codes 99202-99205 and office established patient codes 99212-99215. The lowest level codes, 99201 and 99211, remain unchanged, but, truthfully, those codes are seldom used. The proposed single payment for each category falls between the current reimbursement for Level 3 and Level 4 codes. For example, the current average reimbursement for 99203 is $110, and 99204 is $167, and the proposed bundled rate for 99202-99205 is $135. Also, the documentation required to support the bundled payment will be minimal. One of the options is to document only what is currently required for a Level 2 visit. In theory, the physician can be concise and get to the point instead of filling up the note with unnecessary information, such as a comprehensive 10+ review of systems, past medical, family, and social histories, or an eight-organ system exam that is currently required for office new patient Level 4 or 5 visits.

For most physicians, this is good news! As you can imagine, the response to this portion of the proposal has been emotional on both sides. Some physicians have applauded the proposal, stating the simplicity of documenting and saving time can be spent in direct patient care, expressing that it’s about time CMS did something! On the other hand, administrators, including compliance and billing personnel, are concerned about how these drastic changes will affect the business side of physician services.There are multiple other details within the proposal that will also be a significant change, if adopted, such as a 50% reduction for office procedures with E/M, expanding the ability for office staff to document within the note, and the option to base the E/M code entirely on face-to-face physician/patient time. The full proposal is available on the Federal Register.

At Coker, we perform chart audits and education for multiple employed physician groups and work in tandem with their compliance teams to enforce best practices to ensure appropriate coding and billing to CMS and commercial payers. We are the first to admit that there is quite a bit of subjectivity in the current E/M guidelines that is frustrating to physicians. We often hear physicians say, “Much of the information required is within the note to meet a requirement, but it is not medically necessary for the patient’s treatment.” They go on to say, “Truthfully, we would welcome a more objective, straightforward approach, as we also believe patient care should be primary.”As we’ve talked with clients and others within our industry, we’ve found the proposed changes to office E/M guidelines cause the following concerns:

  • Note, these are only proposed for office E/M, while documentation for E/M performed in other places of service (hospital, nursing facility, ED, and others) will remain under the current 1995/1997 guidelines. How will this affect physicians as they learn an additional way to assign office E/M? Will it increase or decrease confusion?
  • This is a CMS proposal, and the documentation to support an office E/M is significantly reduced. Will commercial and other government payers follow suit? For now, the proposed guidelines include several options for documentation. However, unless more specific criteria are published, it may be difficult for others to do the same.
  • Electronic medical record products have been designed around the current 1995/1997 guidelines including the ability to count or suggest appropriate E/M codes. Additionally, templates have been created to capture the required elements. How will the EMR adjust to the new CMS guidelines while keeping current procedures in place for other payers?
  • How will this affect compensation plans based on RVUs? There will need to be adjustments somewhere along the way, but how will the changes look?
  • It seems those physicians, especially specialists, who code higher level E/M or primary care providers who bill primarily Level 4 visits for patients with multiple comorbidities will probably lose out, while those who code more 99212 and 99213 will see a rise in reimbursement from CMS. How will this affect productivity and staffing models? Will specialists need to see more patients in the day to make up the difference?

No matter where this proposal is headed, adapting to change continues to be a requirement if you want to survive in the healthcare industry. Coker’s Revenue Quality Integrity Team consultants are currently watching these potential changes closely and will be prepared to help our clients and others navigate the changes that come our way.

Sources: Press Release:

CMS Proposes Historic Changes to Modernize Medicare and Restore the Doctor-Patient Relationship, Jul 12, 2018. Available at  https://www.cms.gov/newsroom/press-releases/cms-proposes-historic-changes-modernize-medicare-and-restore-doctor-patient-relationship. Accessed August 24, 2018.

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: A Proposed Rule by the Centers for Medicare & Medicaid Services on 08/09/2018. Available at https://www.federalregister.gov/documents/2018/08/09/C1-2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. Accessed August 24. 2018.

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