CMS Proposed Rule Regarding E/M Visit Payments and Documentation
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.
E/M VISIT REIMBURSEMENT
Current Rule
- Five-tiered coding structure based on visit complexity
- Documentation required to support each code
Proposed Rule
- Would pay providers same rate for all E/M visits coded Level 2 to Level 5
- Proposed blended rate - $135 for new patients and $93 for established ones
- Includes add-on codes to capture services beyond what a standard visit might involve
STREAMLINED DOCUMENTATION AND PROVIDER CHOICE
Current Rule
- Require providers to document text that adds no value to patient care
- Providers waste valuable time "clicking through screens and copying and pasting"
Proposed Rule
- Offers providers more flexibility to conform their documentation to the needs of their practices
- 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 - The rule would establish a minimum documentation requirement with an interval-focused history and exam
- 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
- Impact will vary based on provider specialty, setting, and patient population
- May disadvantage clinicians who provide more complex care
- Majority of specialties, CMS predicts a change of less than 3%
- CMS suspects the biggest winners would be OB/GYN specialists and nurse practitioners, who could enjoy 4% and 3% gains, respectively
- According to CMS, podiatrists, dermatologists, and rheumatologists fare the worst under the model, with expected decreases in payments of 4%, 4%, and 3%
- CMS predicts the reduced administrative burden will make up for any reduction in reimbursement rates
- CMS estimates proposed changes would save an individual provider 51 hours per year, if 40% of his or her patients are Medicare beneficiaries
- CMS predicts that practices’ administrative costs would decline because the new blended payment would eliminate the need to audit against codes
Related Links
- Letter to Doctors from CMS Administrator Seema Verma
- Proposed rule text
- CMS Fact Sheet for Proposed Changes to PFS