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CMS Proposes Changes to Evaluation & Management Requirements

July 25th, 2018 - Wyn Staheli, Director of Research
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It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of stakeholder consensus (with widely varying views among specialties), and differing perspectives on whether code revaluation would be necessary under the PFS as a result of revising the guidelines, which contributed another layer of complexity to the considerations."

The problem has been, and will continue to be, a "lack of consensus" by both providers and payers who "interpret and apply the guidelines as part of their audit processes".

Last year, CMS began the process of making changes and it became clear from the comments that (emphasis added) "any changes would have substantial specialty-specific impacts, both clinical and financial. Based on this feedback, it also seems that the history and exam portions of the guidelines are most significantly outdated with respect to current clinical practice."

CMS is proposing to begin by revising only the E/M guidelines for the Office/Outpatient Evaluation and Management (E/M) codes (99201-99215) in order to assess how well the revisions work. These changes will mean that payment rates will also be revised, so carefully review the proposed RVU information. A summary of the proposed changes which they want to become effective on January 1, 2019 include:

1. Lifting Restrictions Related to E/M Documentation

a. Eliminating Extra Documentation Requirements for Home Visits: Required documentation showing medical necessity for home visits rather than an office visit will be eliminated.

b. Eliminate Restriction of only one E/M visit per day: As integration of care from multiple specialties into one organization has expanded, this has created problems.

2.  Changing Documentation Requirements for Office or Other Outpatient E/M Visits and Home Visits

a. Flexibility in Documentation Options: Providers may choose either Medical Decision Making (MDM), time, or current guidelines (1995 or 1997) as the basis to determine the appropriate level of an E/M visit. Regardless of the method chosen, the payment rate is the same.

b. New Specialty-Specific E/M Codes: Some specialties will have their own E/M codes assigned (new G codes) to describe their services. For example, the proposed rule has two new codes for podiatry E/M services for the initiation of treatment which will be priced similar to ophthalmological service codes 92004 and 92012.

c. Value of Time: Providers may use time as the determining factor regardless of whether or not counseling or care coordination was more than 50 percent of the face-to-face encounter. They are still determining how to best report situations where the time is significantly higher than the two tier payment rate being proposed. It might require the use of the Prolonged Services or other new codes.

d. Less Documentation Required: Providers only need to meet the documentation requirements of a level 2 visit for history, exam, and/or MDM (unless using time) to meet audit requirements. However, for clinical, legal, and operational purposes, it is wise to continue to meet current requirements.

Note: Even though there are reduced requirements, there are still basic standards that are expected for quality of care. Take social history for example. Even though it will no longer be required, it remains an important component to understand the patient's needs and situation to ensure that proper care is provided.

3. Removing Redundancy in E/M Visit Documentation: Remove the requirement to re-document information that is already in the patient's medical record. These aren't required changes. Providers may choose to continue to do things as they are currently doing them.

4. Minimizing Documentation Requirements by Simplifying Payment Amounts: There will only be two payment rates for E/M visits - Level 1 and Levels 2-5. There will be "new add-on codes to better capture the differential resources involved in furnishing certain types of E/M visits". Watch for more information to come regarding these new add-on codes and how to use them.

You will still bill the applicable level with the same CPT codes (99202-99205, 99212-99215), they will just be paid at the same rate. They basically averaged the rates currently being paid to come up with a single rate. While this may decrease revenues, the benefit is that it reduces the problem of audits and payback requests on these codes.

According to the proposed rule, there are three unique E/M visits (listed below) which do not fall under the basic E/M guidelines. There will be new HCPCS G codes assigned to report these services: 

  1. separately identifiable E/M visits furnished in conjunction with a 0-day global procedure
  2. primary care E/M visits for continuous patient care
  3. certain types of specialist E/M visits, including those with inherent visit complexity 

Summary

These proposed changes have the potential to reduce the documentation requirements of healthcare providers allowing them to do what they do best — practice medicine. While CMS wants to implement these changes on January 1, 2019, some commenters have asked for a phased approach to get accustomed to the changes. Delaying implementation will allow time for the AMA to make revisions to CPT code descriptions and guidelines, but that will also delay the opportunity for providers to have less of an administrative headache. Therefore, they are seeking public comment regarding the the implementation date. The comment period closes September 10, 2018. If you wish to comment, the easiest way is to go to http://www.regulations.gov and follow the “submit a comment” instructions. Be sure to refer to file code CMS-1693-P.

This article only contains basic information about these changes. More comprehensive information will be included in FindACode’s specialty-specific Reimbursement Guides for 2019. Go to https://instacode.com/store to pre-order your 2019 copy today.

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