CMS is proposing major changes affecting the way physicians report Evaluation and Management (“E/M”) visits.
CMS Proposal: Practitioners Choice
CMS is proposing that practitioners have a choice:
- Continue to use either the 1995 or 1997 E/M guidelines
- Code and document by time or
- New reporting methodology of MDM only
Using the new MDM only method, the physician would only be required to document a minimum exam and/or history. This will allow practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed.Show More ↓
CMS Proposal: Eliminate Levels 2 through 5
CMS also proposes to eliminate levels two (2) through five (5) all together for reimbursement purposes. If this happens, whichever code category was chosen, New (99202-99205) or established (99212-99215) no matter the visit code, only one reimbursement amount would be paid. [See page 350 for the table and amounts- equal to about the midpoint of current reimbursement for 99203/99204 and 99213/99214]
If this option is implemented, this logic is similar to what happened with OPPS effective Jan. 2016 when all facility visit payments (with exception of ED visits) went from the 992xx codes to G0463.
CMS would provide additional codes to adjust those single rates.
- an E/M multiple procedure payment adjustment to account for duplicative resource costs when E/M visits and procedures with global periods are furnished together;
- HCPCS G-code add-ons to recognize additional relative resources for primary care visits and inherent visit complexity that require additional work beyond that which is accounted for in the single payment rates for new and established patient levels 2 through level 5 visits;
- HCPCS G-codes to describe podiatric E/M visits;
- an additional prolonged face-to-face services add-on G code; and
- a technical modification to the PE methodology to stabilize the allocation of indirect PE for visit services (i) Accounting for E/M Resource Overlap between Stand-Alone Visits and Global Periods”
CMS Proposal: Dual Payment Options
CMS is also proposing if only a dual option of payment level is implemented, additional ‘add on’ HCPCS “G” codes would be reported to “recognize additional resource cost for specialty professionals for certain kinds of visits”.
- Primary care visits would be allowed to add a new code” GPC1X” [worth appx. 0.15 RVU] (p.356) to capture the visit complexities and additional time spent by primary care being the focal point or initial point of patient access to all other healthcare services- or used for established patients supporting their ongoing, more time intensive, communication with their patients.
- Certain specialties would be allowed to report “GCG0X” [worth appx. 0.33 RVU] since their average visit complexities are reported at a higher E/M level historically and seem to require more skill to address multiple and complexities or chronic patient conditions.
- E/M visits reported on the same day as a 0 day global procedure, would be reduced in reimbursement to 50% of the allowable, citing the current overlap in services even the E/M is separate from the work associated with the procedure on the same day.
- For time intensive visits GPRO1 would be implemented for time extending 30 minutes beyond the typical visit time (which is half of 99354) and would reimburse at half of the value of 99354 (1.17 RVU)
CMS Proposal: Podiatry E/M
CMS Proposes another option which involves E/M visits rendered by Podiatrists. They would no longer report E/M visits except in limited circumstances.
CMS would release two HCPCS “G” codes to report podiatry visits with values are much lower than the E/M mid-range single payments, but considering they average much lower levels, this could actually be an increase in one example…
- GPD0X (Podiatry services, medical examination and evaluation with initiation of diagnostic and treatment program, new patient) and
- GPD1X (Podiatry services, medical examination and evaluation with initiation of diagnostic and treatment program, established patient). This change would impact these providers the most, reducing their current average reimbursement annually by about 12%!
CMS Proposal: 2019 Teaching Physician Documentation
Another interesting revision to the PATH documentation guidelines would reduce duplicative entries in the record by the teaching physician (“TP”) and allow the notation of the TP’s presence at the time of service, participation in the review and direction of services by the physician OR A NURSE OR THE RESIDENT! They would no longer have to personally document anything? This is restricted from some services such as: those provided in the hospital, ambulatory, dialysis and psych.
Getting to the doctor can be a challenge for some beneficiaries, whether they live in rural or urban areas. Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly.
“CMS is committed to modernizing the Medicare program by giving access to care using telecommunications technology” by:
- Paying clinicians for virtual check-ins – brief, non-face-to-face appointments via communications technology;
- Paying clinicians for evaluation of patient-submitted photos; and
- Expanding Medicare-covered telehealth services to include prolonged preventive services.
CMS is seeking comments on alternatively using the patient relationship modifiers (implemented in 2018 and currently voluntary) X1-X5 to adjust payments.
Also seeking commentary on how to combine the levels for the ED (99281-99285), make changes to documentation requirements, or something else in the coming years…
They state they hope these options for reporting E/M would simplify coding for E/M visits. They propose to implement this in 1/1/19, but phase it in over time (years) and result in the elimination of what we know today.
You can find the complete proposed rule here:
CMS Panel Discussion on E/M Coding Reform
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