Don’t throw the E&M baby out with the bath water: the proposed CMS changes

By now everyone has heard that the Centers for Medicare and Medicaid Services (CMS) has proposed to dramatically change the way physicians get paid for evaluation and management (E&M) services in the office as part of the proposed 2019 Physician Fee Schedule Rule. In fact, as of the end of July, CMS has received over 600 comments on the proposed rule, with virtually all of them criticizing the proposal. I suspect very few physicians have read the 55 pages describing CMS’ proposal and basing their comments on reporting by various agencies. I don’t fault anyone for not reading it; understanding CMS regulations is not for the faint of heart and I’d rather they spend time reading medical journals or novels and leaving it to those of us who do enjoy such tasks. With that, let me summarize the proposal.

In short, CMS is proposing to establish what they refer to as a blended rate. They looked at all claim data and used the distribution of billed codes over previous years to set a single reimbursement and RVU rate for every 99202-99205 new patient office visit and a single rate for every 99212-99215 established patient office visit. CMS likes blended rates; they use the same concept for paying hospitals under the DRG system. For some visits you get paid more than it costs and for some you get paid less but it all averages out in the end, or so they argue. It is clear that physicians disagree with this premise and are letting CMS know it.

The first question that should come to mind is if there is a flat fee for every visit, why do we even need to select a code? Why not just bill every established patient visit a 99212? CMS explains that they considered establishing a single code for all visits but felt that it would be too much of a disruption to current billing systems. It would also add to confusion since this proposal only applies to Medicare patients and there is no guarantee other payers would adopt the changes. So they elected to continue to use the current code set, and they do say that billing a 99202/99212 for all visits would be appropriate.

The next question is why address only office visits and not hospital visits? Here, CMS was concerned that if they reduced physician documentation requirements there could be downstream effects on a hospital’s ability to meet the Conditions of Participation and they did not have the time to analyze those implications and act accordingly. So, for now, most hospital documentation remains status quo.

And that brings us to the part that most physicians have overlooked. CMS has also proposed allowing physicians to change how they select their E&M code. Physicians must now follow either the 1995 or 1997 E&M guidelines to select a code. CMS recognizes that in doing so, physicians often must document information that is not pertinent to the visit but must be present to choose the code, such as examining and documenting a detailed examination with at least 12 bullets from any organ system to bill a 99203.

Instead, what CMS is proposing is that a physician may pick the E&M code based on the current system, the amount of time spent with the patient, or solely based on medical decision-making (MDM) guidelines for the code. The option to choose time would change in that it would be based completely on total face-to-face time with the patient and not limited to visits where over 50 percent of the visit is counseling and/or coordination of care as it is at present.

As an example of using MDM as the sole factor, if you have a patient with type II diabetes, hypertension, and hyperlipidemia, you review their pertinent history, review their recent labs, and advise them to continue their medications, you have moderate complexity medical decision-making and can choose 99214. You would not be required to meet the detailed history or detailed examination requirements to bill that code as would be required with the current guidelines. Of course, if the examination you feel is warranted for the visit includes 12 bullets, or an extended history with 4 elements of the history, two to nine items of review of systems and one social history item is warranted, that is fine. But if only vital signs and a foot examination are warranted, then that is all you need to perform and of course document. I think this is a proposal we all can embrace.

The other overlooked part of the proposal is the add-on codes for primary care services. Although not of great value, the cumulative effect of this code added to every primary care service can be up to $20,000 a year for a primary care physician. It should be noted that CMS is proposing to allow certain specialists, such as cardiology, ENT, urology, and interventional pain to also bill an add-on code for primary care services they provide, and CMS has given their add-on code a higher weight. I personally find this a bit insulting to primary care physicians who once again are being “devalued” compared to procedure-oriented specialists but we should not look a gift horse in the mouth.

While it is important for physicians to continue to express their dislike of the CMS proposal to “blend” office visit rates, I’d like to see a groundswell of support for the CMS proposal to allow time or MDM to be adopted for choosing the appropriate E&M code, along with support for the new primary care add-on service code. I would hope that CMS would see the benefit to physicians and patients by separating these proposals and adopting these two for 2019.

Physicians can submit their comments until September 10th.

Ronald Hirsch is vice-president, Physician Advisory Services, R1 RCM, Inc. and can be reached on Twitter @signaturedoc. The opinions expressed in this article represent the personal views of the author and do not represent the views or recommendations of R1 RCM, Inc.

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