Proposed E&M code changes would impact specialty physicians.

Some physicians are probably not very happy with recently proposed changes to the Medicare Physician Fee Schedule.

The Centers for Medicare & Medicaid Services (CMS) designed the changes to reduce paperwork and enable physicians to spend more time with patients. Those seem like good ideas. However, CMS may face pushback from specialty physicians who will see significantly lower reimbursements for their most complex patients under the new fee schedule.

The proposed changes affect evaluation and management (E&M) coding for office and outpatient visits. CMS proposed to chang the reimbursement schedule for new patients and established payments from five separate levels to two. Although the new reimbursements are higher for levels 1-3, they are lower for levels 4-5, which represent more complex cases commonly seen by specialty physicians.

To better explain how the E&M code changes could impact specialty physicians, here is a hypothetical comparison of a visit to a family practice physician and a visit to a specialist, emphasizing the difference in reimbursement.

Scenario 1: A 56-year-old male patient presents to his family practice physician’s office for a six-month evaluation of his hypertension and long-term use of Lipitor for hyperlipidemia. On examination, the physician documents the patient’s blood pressure as 144/90 and his most recent LDL at 131.

The physician recommends that this patient continue to take Lipitor for hyperlipidemia and prescribes Ziac (2.5 mg/6.5 mg) for hypertension. She tells the patient to return in six months for a follow-up exam and complete blood workup.

The patient has two established diagnoses. The provider reviewed his clinical lab tests and provided prescription drug management.

The CPT® code assigned by the family practice for this office visit would be 99213 (medical decision-making low complexity). Under the previous rule, reimbursement would be $74. Under the new rules, reimbursement would be $93.

Scenario 2: A 62-year-old female patient presents to the endocrinologist with altered mental status, increased sweating, tingling of extremities, and weakness. The patient has chronic pancreatitis, causing diabetes, coronary artery disease, and hypertension. She is currently on a sliding scale of Humalog to control her diabetes.

Just recently, the patient was placed on Tresiba. Tests indicated that her blood glucose level was 37 mg/dL. The patient was given IV glucose. When reassessed, her blood glucose level was 86 mg/dL. Her vital signs showed blood pressure 160/110 mm Hg, pulse 82 beats per minute, respirations 16 breaths per minute, SaO2 98 percent on room air.

Due to the patient’s elevated blood pressure, fluctuating blood glucose levels, and other symptoms, the endocrinologist instructs her to go to the hospital. He contacts the hospitalist on call and facilitates her admission.

The patient had four established diagnoses, with two worsening, and a chronic illness that posed a threat to life or bodily function. The provider ordered tests, reviewed the results, treated the patient with intravenous glucose, and arranged for her to be admitted to the hospital.

The CPT® code assigned by the endocrinologist for this office visit would be 99215 (medical decision-making high complexity). Under the previous rule, reimbursement would be $148. Under the new rules, reimbursement would be $93.

Focus on Medical Decision-Making

The previous rules were driven by three key components: history, exam, and medical decision-making. The new rule focuses solely on medical decision-making.

This change places greater pressure on physicians to provide detailed documentation to support the complexity of establishing a diagnosis and/or selecting a management opinion or treatment plan. Physicians must also document all possible diagnoses to be considered, including the following:

  • Amount and/or complexity of data to be obtained, reviewed, and analyzed
  • Risk of significant complications, morbidity, and/or mortality associated with the patient’s presenting conditions
  • Diagnostic procedure(s)
  • Possible management options or treatment plans

Finally, providers need to continue to focus on what is needed to report risk adjustment and quality initiatives. 

The proposed rules regarding the Physician Fee Schedule discussed in this article, along with other rules, are currently under review. If you have comments, you can submit them to CMS before midnight on Sept. 10 using the following link:

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