Fee schedule final rule: CMS postpones E/M changes to 2021
Grant Huang, CPC, CPMA
Director of Content for DoctorsManagement
It turns out CMS will not upend E/M coding and documentation guidelines that have, for all of their ambiguities and imperfections, been in effect for more than 25 years – at least, not yet. In its Medicare 2019 Physician Fee Schedule (PFS) final rule, CMS is postponing all E/M changes to 2021, compromising at least in part with various stakeholder groups alarmed by the sudden, dramatic changes being proposed.
In a nutshell, CMS wanted to base code levels on the medical decision making (MDM) component and face time spent, deemphasizing the history and exam requirements, while also blending payments for E/M codes from 10 distinct levels in the outpatient setting to just two. In fact, all the proposed changes were limited to the outpatient codes (CPT 99201-99215).
What’s happening in 2021? By pushing the implementation date for its E/M changes back two years, CMS hopes to give providers more time to plan and prepare, though the final rule also changes the provisions proposed. Here’s a look at these changes in detail:
- Documentation requirements will be relaxed.CMS will proceed with what it calls an effort to reduce “administrative burden” in 2021 by making MDM and face time the key determinants of code level, though it will still require a level of history and exam to be documented at a 99212/99202 level (expanded problem focused history, expanded problem focused exam). Also, CMS will allow ancillary staff such as medical assistants to capture the chief complaint and history of present illness (HPI), though the physician will need to indicate that he/she still reviewed them for accuracy.
- Blended payments won’t include level 5 codes.While CMS will still blend payments for levels 2-4, the maximum level codes 99205 (new patient) and 99215 (established payment) will retain current payment amounts subject to the 2021 conversion factor. “We are not finalizing the inclusion of E/M office/outpatient level 5 visits in the single payment rate, to better account for the care and needs of particularly complex patients,” CMS states in the final rule.
- Add-on G-codes adopted except for podiatry services. To offset the price reduction of level 4 visits due to the new blended rates, CMS had proposed creating new HCPCS codes (G-codes) for primary care services, specialty services, and extended care (the new moniker for prolonged services). These will be finalized in 2021, though the dollar amounts will not be particularly high.
- Modifier 25 reduction won’t be finalized. CMS had suggested reducing reimbursement for the procedural CPT code associated with an E/M code that had modifier 25 appended but, owing to significant provider backlash, this provision was axed. CMS could look for other ways to challenge modifier 25 use, and stated that it continues to have “significant concerns about the appropriate payment when codes with global periods, especially 0 and 10-day global periods, are billed on the same day as an E/M visit.”
- Allowing same-day E/M codes by two physicians of same specialty. CMS will not move forward with a proposal to allow two physicians of the same specialty and group to bill an E/M code on the same day. The agency offered little explanation beyond that it had yet to determine the impact of this provision on Medicare expenditures and patient cost-sharing.
Predicting the future of E/M
The 2019 PFS final rule represents CMS colliding with the realities of clinical care, reflected in the sheer volume of comments the agency received during the proposed rule-making process. Many of the comments concerned payment, with the blended payment rates creating winners and losers by specialty, based on how those specialties have historically selected E/M levels. Those that tended to bill higher-level outpatient codes would see a significant pay cut, while those that tended to bill lower-level codes would see a significant boost.
“We appreciate the issues raised by commenters but continue to believe our proposals allowing for flexibility in how E/M office/outpatient visit levels are documented and the applying of a minimum documentation standard as a corollary to establishing single payment rates for E/M office/outpatient visits will significantly reduce burden for clinicians and support them in making coding and documentation decisions that better align with current medical practice,” CMS writes in the final rule.
Assuming CMS does not further delay the E/M changes, 2021 will be a year of change – but perhaps not as significant as you may think. First, CMS speaks for Medicare, and commercial payers have been coy on whether they would follow the agency in altering their E/M guidelines. Second, the changes affect outpatient codes only, while the existing requirements would stay the same for inpatient services and other places of service (e.g. emergency department codes).
Can you expect physicians who work daily in multiple places of service to relax documentation in the outpatient setting but keep doing things the way they always have in the other settings? The workflow changes alone could offset the CMS-promised gains in administrative efficiency.
Stay tuned. We’ll be posting a comprehensive breakdown of the remaining provisions in the 2019 PFS final rule, including significant boosts to telehealth services, in the near future.
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