Pocket Guide to New E&M Service Changes

CMS recently released the final rule for the Medicare Physician Fee Schedule.

Before I dive into the specifics of the recently released 2019 final rule for evaluation and management (E&M) services, allow me to quickly speak to three elements that the Centers for Medicare & Medicaid Services (CMS) has not finalized that are of equal importance.

CMS is not finalizing aspects of the proposal that would have:

1. Reduced payment when E&M office/outpatient visits are furnished on the same day as procedures; this means there will be no 50 percent reduction for a procedure furnished on the same day as an E&M service with Modifier 25;
2. Established separate coding and payment for podiatric E&M visits; or
3. Standardized the allocation of practice expense relative value units (RVUs) for the codes that describe these services.

For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E&M office/outpatient visits, and providers should continue to use either the 1995 or 1997 E&M documentation guidelines to document such office/outpatient visits billed to Medicare.

For CY 2019 and beyond, CMS is finalizing the following policies:

• For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.
• Additionally, CMS is clarifying that for E&M office/outpatient visits, for new and established patients, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.
• There will be removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E&M visits furnished by teaching physicians. 

Beginning in CY 2021, CMS will further reduce administrative burdens with the implementation of payment, coding, and other documentation changes. Payment for E&M office/outpatient visits will be simplified, and payment will vary primarily based on attributes that do not require separate, complex documentation.

Specifically, for CY 2021, CMS is finalizing the following policies: 

• Reduction in the payment variation for E&M office/outpatient visit levels, achieved by paying a single rate for E&M office/outpatient visit levels 2 through 4 for established and new patients while maintaining the payment rate for E&M office/outpatient visits of level 5, in order to better account for the care and needs of complex patients;
• Permitting practitioners to choose to document E&M office/outpatient level 2 through 5 visits using medical decision-making (MDM) or time instead of applying the current 1995 or 1997 E&M documentation guidelines – or, alternatively, practitioners could continue using the current framework;
• Beginning in CY 2021, for E&M office/outpatient levels 2 through 5 visits, CMS will allow for flexibility in how visit levels are documented – specifically, introducing a choice to use the current framework, MDM, or time. For E&M office/outpatient level 2 through 4 visits, when using MDM or the current framework to document the visit, CMS will also apply a minimum supporting documentation standard associated with level 2 visits. For these cases, Medicare would require information to support a level 2 E&M office/outpatient visit code for history, exam, and/or medical decision-making;
• When time is used to document, practitioners will document the medical necessity of the visit and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary;  
• Implementation of add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care, although they would not be restricted by physician specialty. These codes would only be reportable with E&M office/outpatient level 2 through 4 visits, and their use generally would not impose new per-visit documentation requirements; and
• Adoption of a new “extended visit” add-on code for use only with E&M office/outpatient level 2 through 4 visits to account for the additional resources required when practitioners need to spend extended time with the patient.

CMS believes these policies will allow practitioners greater flexibility to exercise clinical judgment in documentation, so they can focus on what is clinically relevant and medically necessary for the beneficiary.

CMS intends to engage in further discussions with the public to potentially further refine the policies for CY 2021.

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