CMS proposes to change physician evaluation and management (E&M) coding with a drastic overhaul.

EDITOR’S NOTE: The following report first appeared on RACmonitor on July 13, 2018

After soliciting comments from many stakeholders in the last year, the Centers for Medicare & Medicaid Services (CMS) has just proposed sweeping changes to the way physicians bill for evaluation and management (E&M) services in the 2019 Proposed Physician Fee Schedule Rule.

The Proposed Rule contains much more but this summary will be limited to the E&M changes.

The proposals are summarized below. Note that for each, CMS is seeking comment and the final regulation may differ from the description I provide.

  • Home visits will no longer require a statement of why the visit is required at home instead of the office.
  • Practitioners from the same group and specialty will be able to bill for visits on the same day if clinical circumstances warrant additional visits.
  • Practitioners may use either the current E&M standards for coding office visits, may use strictly time spent with the patient, or may use solely Medical Decision Making. But at the same time, they are proposing to adopt a single payment for every new patient visit and a single payment for every established patient visit.
  • Practitioners would no longer be required to personally document the patient history, as they do now. They may review a history entered by “ancillary staff or the patient” and indicate they verified it.
  • Office visits furnished on the same day as a procedure with a global period=0 that are billed with modifier -25 would be paid at a 50 percent discount.
  • A G code will be established that can be billed with any primary care established patient E&M visit to add additional RVUs to the payment to account for the additional resources of the cognitive work of primary care physicians (and specialists who provide primary care services).
  • A separate G code will be established for use for E&M office visits by specialists in the following specialties: endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, and interventional pain management. This will add additional RVUs to the E&M visit weight account for the complexity of the issues facing Medicare patients cared for by these specialties.
  • A new prolonged services G code will be established for care 30 minutes beyond the typical time for the base code.
  • There were no proposed changes to the Emergency Department E&M codes, but CMS did ask for comments on possible changes, noting that the feedback they have received so far indicates that “rather, commenters believed that a greater percentage of emergency department visits are at a higher acuity level, payers often do not pay at a higher level of care and the visit is often inappropriately down-coded based on retrospective review.”
  • CMS is proposing to adopt these changes on January 1, 2019 but soliciting comments on delaying implementation for a year until January 1, 2020.

CMS provided a payment example:

“As an example, in CY 2018, a physician would bill a level 4 E/M visit and document using the existing documentation framework for a level 4 E/M visit. Their payment rate would be approximately $109 in the office setting. If these proposals are finalized, the physician would bill the same visit code for a level 4 E/M visit, documenting the visit according to the minimum  documentation requirements for a level 2 E/M visit and/or based on their choice of using time, MDM, or the 1995 or 1997 guidelines, plus either of the proposed add-on codes (HCPCS codes GPC1X or GCG0X) depending on the type of patient care furnished, and could bill one unit of the proposed prolonged services code (HCPCS code GPRO1) if they meet the time threshold for this code. The combined payment rate for the generic E/M code and HCPCS code GPRO1 would be approximately $165 with HCPCS code GPC1X and approximately $177 with HCPCS code GCG0X.”

It should be noted that while the proposed changes will have a profound influence on physician documentation, such as elimination of the need for a “12 Point Review of Systems” or documentation of the family history on a 90-year-old patient, CMS was clear that it does not to see a decline in the quality of care provided to patients if physicians stop asking crucial questions in the patient’s history.

CMS stated that “our expectation is that practitioners would continue to perform and document E/M visits as medically necessary for the patient to ensure quality and continuity of care. For example, we believe that it remains an important part of care for the practitioner to understand the patient’s social history, even though we would no longer require that history to be documented to bill Medicare for the visit.”

The proposed rule can be found here:

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Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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