2018 Year End Wrap Up 2018 Year End Wrap Up

2018 Year End Wrap Up

Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC

Partner and Vice President of Compliance at DoctorsManagement

This auditing and compliance “Tip of the Week” was originally published by the
National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

Now that we are quickly approaching the end of 2018, which by the way is so hard to believe, we need to be looking ahead to 2019 and getting our collective selves together to ensure we are prepared for what the new year will have in store. Payers’ aggressive stance on complete and accurate coding and documentation requirements is not slowing down and neither should your efforts to ensure compliance. As with each year, I try to provide you, my faithful reader, with a recap of the year that was and how I think it is going to impact the industry in the new year!

CMS’ Final Rule

By now we are all familiar with what CMS decided to do in 2019 and beyond with regards to a single payment for new and established evaluation and management codes. Additionally, while their plan for that payment reduction/increase did not go into effect, it is still on the books for 2021 and as a matter of fact that rule has been finalized.

Below (1-3) are items that did NOT go into effect in 2019:

(1) Reduced payment when E/M office/outpatient visits are furnished on the same day as procedures; this means there will be no 50% reduction for a procedure furnished on the same day as an EM with Modifier 25.

(2) Established separate coding and payment for podiatric E/M visits.

(3) Standardized the allocation of practice expense RVUs for the codes that describe these services.

For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and providers should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare.

For CY 2019 and beyond, CMS is finalizing the following policies (This information is taken directly from the CMS Fact Sheet 11/2018) with minor modification for the reader:
  • 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, CMS is clarifying that 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’s 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. Payment for E/M office/outpatient visits will be simplified and payment would vary primarily based on attributes that do not require separate, complex documentation.

Specifically for CY 2021, CMS is finalizing the following policies:
  • 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, CMS will allow 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, CMS will also apply a minimum supporting documentation standard associated with level 2 visits. 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 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.

CMS believes these policies will allow practitioners greater flexibility to exercise clinical judgment in documentation, so they can focus on what is clinically relevant and medically necessary for the beneficiary.

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
  2. Read more: What can you expect from a coding and compliance review?
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