Responses to Proposed E&M Code Changes Emerge: CMS, Are You Listening?

Reactions have been particularly negative thus far..

Outrage, disbelief, and anger tend to characterize the tone of comments regarding the Centers for Medicare & Medicaid Services’ (CMS’s) proposed evaluation and management (E&M) code changes tucked into the recently posted 2019 Medicare Physician Fee Schedule.

And although CMS has indicated that it is looking for stakeholder comments, the volume and tenor of the reaction might be more than the agency anticipated.

“I have not looked at every comment, but the overwhelming sentiment seems to be that a blended payment rate for every office visit is not going over well with physicians,” Ronald Hirsch, MD, told RACmonitor. “The response seems unprecedented; physicians rarely respond to CMS regulatory proposals in such numbers.”

To unpack, CMS is proposing to reimburse new patient visits at a single flat rate for codes 99202-99205 (99201 would be paid at a lower rate), while a corresponding, lower flat rate would apply to established patient visit codes, 99212-99215. Code 99211 would also be paid a lower rate. The level 1 codes don’t get the flat rate because they don’t require the presence of a physician.

As of this writing, 618 responses had been posted to a CMS website, https://www.regulations.gov.

Here is a sample of the comments, ranging from visceral to rational.

“I am an emergency medicine physician in Massachusetts,” one physician wrote. “I am extremely concerned about the proposed revision of payment policies regulation. The hardest work we do as physicians is the intellectual work of managing complex patients. This is also the riskiest and most time-consuming work (far more so than procedures).”

One of the touted benefits in the proposed rule is the reduction of the burden of physician documentation. In response here is what the same physician wrote:

“In attempting to simplify documentation and simplify billing – all to (reach) a lower level of reimbursement – this regulation will disincentivize the physicians from taking on those complex patients and caring for them. In effect, physicians will either cherry-pick a practice full of relatively healthy patients with simple health needs, or they will drop out of Medicare altogether. This plan seems to be crying out for a pilot phase in a small market to test its effects in the real world.”

The physician suggested that “rolling this out nationwide without testing and fine-tuning it first could result in massive disruption of our entire health system, with a resulting backlash against CMS and the executive branch.”

In another response to the CMS proposal, a commenter wondered about the auditing implications associated with claim payment.

“Focusing on time spent and medical decision-making for E&M documentation is a step in the right direction. It will definitely help to reduce some burden to providers,” the comment read. “However, how will providers be evaluated and held financially accountable for accurate code submission if the payment for all levels of service is the same?” 

Continuing, this commenter reasoned that the “proposed rule allows for four distinct CPT® codes level 2-5, with distinct medical decision-making requirements for each level but with single payment for all levels.”

“This single payment for distinct services will confuse providers, auditors, and other payers who base their fees on Medicare’s fee schedule or who follow Medicare guidelines for documentation,” the comment continued. “There is still a need for medical decision-making to be documented accurately for all visits, so the payment should also reflect distinct payment amounts for each level of service. Otherwise, all of the work that CERT (Comprehensive Error Rate Testing) auditors have done to educate providers on reporting codes that reflect the services performed will be undone.” 

“Please advise,” the same comment also read, “how claim payment will be handled if a Medicare contractor reviews documentation for a visit and it does not meet documentation requirements of time or medical decision-making? Will denials for insufficient documentation no longer be issued for any 2-5 service?” 

This commenter concluded by advising CMS that “coding educators, auditors, and documentation analysts will have a hard time holding providers accountable for properly documenting their medical decision-making if the payment doesn’t reflect the need.”

Not all comments were as reasonably stated as the aforementioned response. One physician cut right to the chase:

“These cuts are disturbing, and you have made doctoring into a joke,” the physician wrote. “We as physicians sacrifice so much of our lives and time to do our work, and now we’re being disrespected for doing so. Keep going down this road by cutting physician pay, and nobody will go to medical school.” 

Another physician explained the difficulty to be faced if the proposal becomes final for physicians who treat chronically ill patients.

“As a family physician who sees primarily older, chronically ill patients with multiple complex comorbidities, being paid essentially the equivalent of a level 3 visit for what should be a 5 based on effort, time, complexity, and documentation is a major step backwards for physician payment and patient care,” the commenter wrote. “This would force physicians who care for the sickest and most complex patients to either drop the panel for a young and well panel of patients who can be seen very quickly, or to make these elderly and ill individuals come in over and over for one issue at a time, which is neither efficient nor holistic. I suggest you go back to the drawing board on this.”

Adding to the national discourse on the proposed rule, the New York Times recently chimed in with an article in a recent Sunday edition, explaining to readers that under the CMS proposal, Medicare would pay physicians certain amounts “regardless of a patient’s condition or the complexity of the services provided.”

In echoing the observation made by the New York Times reporter, one physician summed up the situation that most would agree is the fundamental flaw in the proposed rule.

“To equate a simple blood pressure check for (one) patient with the evaluation and management of another patient with Chronic Obstructive Pulmonary Disease (COPD), diabetes, hypertension, dyslipidemia, vascular disease, dementia, and the slew of other problems a primary care doctor must address in one visit is ludicrous,” the physician wrote. “It will force us as physicians to address just one problem per visit, which patients will not stand for. In the end, the doctor will do the work and not be paid for their training, expertise, and experience. We already have hours of uncompensated time – not just filled with paperwork, but with such things as evaluating labs and imaging studies, conversing with one another about proper care for a patient, not to mention refilling prescriptions.”

Treading on the domain of hospital administrators, the physician asked one question on the minds of many others.

“Why is cost saving always at the expense of physicians, without whom there would be no income for anyone?” the physician asked. “How about cost cutting by eliminating some administrators’ salaries?”

In one comment, a physician expressed appreciation of CMS efforts to mitigate what many physicians consider to be a serious issue of being overly tethered to the electronic medical record (EMR) – while at the same time disagreeing with proposed rule.

“Hello,” began the commenter politely. “I’m a physician, and I thank you for considering ways to reduce EMR burden. I don’t support the current proposal, because it will greatly reduce payments to practices with a high proportion of complex patients with visits that require more time. This penalizes physicians spending the appropriate amount of time evaluating and treating complex patients, and incentivizes physicians to only take on healthy patients who do not require as much time.”

In conclusion, the physician asked CMS to find a way to reduce clicks needed in the EMR, and to reduce the amount of data that requires tracking.

“You’ll have to give us back a little trust,” the physician wrote. “Micromanagement has eroded the morale of the medical workforce and the quality of care.” 

Not pulling any punches, one physician flatly told CMS that this proposal was not good for healthcare.

“This will kill medicine,” a physician stated unequivocally. “It (the proposed rule) will reward patient mills that see patients like cattle. You can limit complex patients, limit the number of complaints patients can have, limit how much time you spend with them, and be rewarded.”

“Those of us that spend time with patients, accept medically complex patients, and address numerous complaints in one visit will be forced into bad medicine,” the physician continued. “I will be forced to stop accepting Medicare if these changes go through, because I will not be a patient mill.”

Even more emphatic was one response from a physician in rural North Carolina.

“What an absolute disgrace,” the physician wrote. “So, as an independent PCP (primary care physician) in rural North Carolina, the visits for my elderly patients that literally cover 11 different problems will earn me the same as a simple bronchitis? If this goes through, I will not be able to see Medicare patients.”

Explaining to CMS that this area is already underserved, the physician facetiously suggested that patients could come in once a week so as to address each of their problems separately.

“Nicely done, boys,” said the physician. “Get out of the way and let the real doctors in the trenches fix this crap.”