CMS Proposed Rule Regarding E/M Visit Payments and Documentation

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On July 12, 2018, CMS proposed a number of payment and documentation changes to reduce administrative burden and eliminate “misvaluation” of codes for outpatient Evaluation & Management (E/M) visits furnished under the Medicare Physician Fee Schedule (PFS). Two of the proposed changes are outlined below and will fundamentally alter how CMS pays for E/M visits and how providers document those encounters. The comment period ends September 10, 2018. The final rule will take effect January 1, 2019.


Current Rule

  • checkmark Created with Sketch. Five-tiered coding structure based on visit complexity
  • checkmark Created with Sketch. Documentation required to support each code

Proposed Rule

  • checkmark Created with Sketch. Would pay providers same rate for all E/M visits coded Level 2 to Level 5
  • checkmark Created with Sketch. Proposed blended rate - $135 for new patients and $93 for established ones
  • checkmark Created with Sketch. Includes add-on codes to capture services beyond what a standard visit might involve


Current Rule

  • checkmark Created with Sketch. Require providers to document text that adds no value to patient care
  • checkmark Created with Sketch. Providers waste valuable time "clicking through screens and copying and pasting"

Proposed Rule

  • checkmark Created with Sketch. Offers providers more flexibility to conform their documentation to the needs of their practices
  • checkmark Created with Sketch. Providers would be able to use one of three methods to determine appropriate level for any E/M visit:
    (1) the current framework under the 1995 or 1997 documentation guidelines;
    (2) medical decision-making; or
    (3) time
  • checkmark Created with Sketch. The rule would establish a minimum documentation requirement with an interval-focused history and exam
  • checkmark Created with Sketch. Physicians could simply verify some information entered into the record by an ancillary staff member or a beneficiary instead of re-entering that data

Impact of proposed regulations

  • checkmark Created with Sketch. Impact will vary based on provider specialty, setting, and patient population
  • checkmark Created with Sketch. May disadvantage clinicians who provide more complex care
  • checkmark Created with Sketch. Majority of specialties, CMS predicts a change of less than 3%
  • checkmark Created with Sketch. CMS suspects the biggest winners would be OB/GYN specialists and nurse practitioners, who could enjoy 4% and 3% gains, respectively
  • checkmark Created with Sketch. According to CMS, podiatrists, dermatologists, and rheumatologists fare the worst under the model, with expected decreases in payments of 4%, 4%, and 3%
  • checkmark Created with Sketch. CMS predicts the reduced administrative burden will make up for any reduction in reimbursement rates
  • checkmark Created with Sketch. CMS estimates proposed changes would save an individual provider 51 hours per year, if 40% of his or her patients are Medicare beneficiaries
  • checkmark Created with Sketch. CMS predicts that practices’ administrative costs would decline because the new blended payment would eliminate the need to audit against codes
Related Links
  1. Letter to Doctors from CMS Administrator Seema Verma
  2. Proposed rule text
  3. CMS Fact Sheet for Proposed Changes to PFS

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