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PROPOSED RULE: CHANGES TO EVALUATION AND MANAGEMENT PAYMENT POLICY
Doctor to Doctor

CMS is preparing policies to make the process of Evaluation and Management documentation easier so that paper burden could lighten in new 2019 year. Although this project gives a negative reaction as well, let's look through it in details in this article. It is planned as a long process since 2019 till 2021. Most hateful change is replacement of 5 levels of office visit with 2 levels will begin in 2021 under proposed rule

For CY 2019 and 2020 CMS is planning to implement several policies to provide immediate reduction of paper burden. List of policies to implement

  • Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visi
  • 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, for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’ 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; and
  • 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 burden with the implementation of payment, coding, and other documentation changes. The following policies will be implemented:

  • Reduction in the payment variation for E/M office/outpatient visit levels 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 visit 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 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, it will be allowed for flexibility in how visit levels are documented— specifically a choice to use the current framework, MDM, or time. For E/M office/outpatient level 2 through 4 visits, when using MDM or current framework to document the visit, also a minimum supporting documentation standard associated with level 2 visits will be applied. 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, though they would not be restricted by physician specialty. These codes would only be reportable with E/M office/outpatient le 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.

This table is to illustrate the approximate difference that will appear after implementation changes from the proposed rule in CY 2021:

HCPCS Code Current Nonfacility Payment Rate Proposed Nonfacility Payment Rat
NEW PATIENT OFFICE VISIT
99201 $45 $44
99202 $76 $135
99203 $110 $135
99204 $167 $135
99205 $211 $135
ESTABLISHED PATIENT OFFICE VISIT
9921 $22 $24
99212 $45 $93
99213 $74 $93
99214 $109 $93
99215 $148 $93

It is said here, that these changes will provide practitioners with greater flexibility to exercise clinical judgment in documentation and to focus on what is clinically relevant and medically necessary for the beneficiary. There will be further discussions with the public to improve projected policies for CY 2021

Also, according to some comments, CMS is not finalizing aspects of the proposal would have

  • reduced payment when E/M office/outpatient visits are furnished on the same day as procedures,
  • established separate coding and payment for podiatric E/M visits, or
  • standardized the allocation of practice expense RVUs for the codes that describe these services.

In her letter to physicians, CMS Administrator Seema Verma says: “Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant 3 reduction in documentation burden. If you add up the amount of time saved for clinicians across America in one year from our proposal, it would come to more than 500 years of additional time available for patient care.

As it was said in our previous issues CMS welcomed any comments and offers. These changes may stay unnoticeable by narrow group of practitioners, but those, who usually provide 4th or 5th level of office visit, will definitely feel the difference. To cover up the difference these providers will try to see more patients but for the smaller period of time. And from the patients’ side this change will become a negative point for sure, as they would have to return for more follow-up visits.

There is some time to consider and share your thoughts and there is some time for CMS to refine the project and maybe come up with a better solution.

Doctor to Doctor

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Insights
November 2018