Administration Proposes Major Changes to Evaluation and Management Coding

  • CMS is proposing to pay a standard reimbursement rate for E/M levels 2 through 5.
  • CMS is also proposing many changes to the documentation requirements for E/M visits.
  • CMS would also apply a 50 percent MPPR reduction for certain E/M visits.

Perhaps the most significant proposal in the 2019 Medicare Physician Fee Schedule (PFS) proposed rule is the Administration’s plan to change the documentation requirements and payment structure for Evaluation and Management (E/M) codes performed in office or outpatient settings. Specifically, the proposal would simplify the documentation requirements and consolidate the five E/M codes into two levels with an add-on payment for certain specialties.

The Centers for Medicare and Medicaid Services (CMS) intends for these proposed changes to take effect on January 1, 2019, but is also considering delaying implementation until January 1, 2020, to allow industry time to prepare for compliance.

In the 2018 PFS proposed rule, CMS sought public recommendations for how it could update the 1995 and 1997 E/M coding guidelines that are used to justify and document the appropriate E/M code for a visit.

CMS ultimately did not adopt any changes to the E/M coding guidelines or billing requirements in the final rule, instead stating that it would spend the year studying the various recommendations from stakeholders about revisiting the coding guidelines. CMS’ proposal in the 2019 PFS was rather unexpected in that CMS had not discussed proposing such drastic changes in previous regulations. It was especially surprising to read that CMS is proposing to pay a single rate for E/M visit levels 2 through 5.

CMS believes this will reduce burden on providers by curtailing the amount of work it takes to document what is sometimes a subjective determination for what is the correct visit level and preventing the need for subsequent audits. CMS also believes this will eliminate the “increasingly outdated distinction between the kinds of visits that are reflected in the current CPT code levels.”

CMS modeled this proposal based on the 2018 Medicare PFS Conversion Factor. If the proposed E/M reimbursement methodology was in place in 2018, E/M levels 2 through 5 would be paid at $135 for new patients and $93 for established patients.

CPT Code CY 2018 Non-Facility Payment Rate Proposed Non-facility Payment Rate 99211 $22 $24 99212 $45 $93 99213 $74 99214 $109 99215 $148

The proposed 2019 PFS Conversion Factor (CF) update is only a slight change ($0.06) from the finalized 2018 CF. Therefore, assuming the proposed 2019 CF is finalized, the rates outlined in the 2018 model should be an accurate indication of what the actual rates will be under the proposal.

The proposed rate for E/M levels 2 through 5 would be a higher payment than the current E/M level 2 and 3 payments but lower than the current E/M level 4 and 5 payments. Recognizing that some specialties that treat a higher proportion of E/M levels 4 and 5 would be adversely affected by this change, CMS is proposing to create a new HCPCS code that will add on $14 to the proposed E/M consolidated rate. Only select specialties are eligible for this add on payment.

The proposed code for this add on payment is GCG0X (Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care (Add-on code, list separately in addition to an evaluation and management visit)).

CMS is also proposing a $5 add-on payments for complex primary care visits and a $67 add-on payment for a 30 minute prolonged visit.

Under the proposal, providers would still be required to use the current CPT codes on claims despite the new payment rates.

CMS is also proposing to apply a Multiple Procedures Payment Reduction (MPPR) for E/M services performed with procedures with global periods. Specifically, CMS is proposing to reduce payment by 50 percent for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier -25.

In addition to changing the payments for E/M services, CMS is also proposing to make the documentation requirements easier for providers to follow. CMS believes that many of these 6 revisions would correct outdated documentation policies and that by simplifying the requirements CMS will reduce administrative burdens on providers.

CMS is also proposing several significant changes to the E/M documentation requirements. For example, CMS is proposing to allow providers to base E/M coding determinations on either medical decision-making (MDM) or time in addition to the current E/M coding guidelines from 1995 and 1997.

Time can already be used as a justification for visits where counseling and/or coordination of care accounts for more than 50 percent of the face-to-face physician/patient encounter. CMS is proposing to broaden the definition to allow time as a justification for any visit.

For visits that fall within the new payment rate for level 2 through 5 E/M visits, CMS is proposing to establish a minimum documentation standard whereby providers will only be required to meet the documentation requirements currently associated with a level 2 E/M visit for claims that use the current E/M guidelines or the newly proposed MDM justification.

Even though CMS would only require the necessary documentation to support a level 2 visit, CMS expects that providers will continue to document information for the appropriate level of care furnished for clinical, legal, operational or other purposes.

A different documentation standard would apply for claims that use time, as proposed, to determine the E/M visit level. CMS would require providers to document the medical necessity of the visit and show the total amount of time spent by the billing practitioner face-to-face with the patient.

In response to stakeholder feedback that it is redundant to require documentation of information in the billing practitioner’s note that is already present in the medical record, particularly with regard to history and exam for established patients, CMS is proposing to only require providers to document what has changed since the last visit. The proposal would also require documentation of pertinent items that have not changed since the last visit.

CMS is proposing to relax the requirement for a teaching physician to personally document their participation in an E/M procedure in the medical record for visit performed by a provider under their supervision. CMS is proposing to change the requirements so that the medical record must only document that the teaching physician was present at the time the service was furnished. The teaching physician does not have to be the one to document this information.

CMS is also considering (but not proposing) eliminating its prohibition on billing same-day E/M visits by providers of the same specialty within a group. Currently, CMS will not pay two E/M office visits billed by a provider (or provider of the same specialty from the same group practice) for the same beneficiary on the same day unless the provider documents that the visits were for unrelated problems which could not be provided during the same encounter.

CMS believes that eliminating this policy would reflect the changing practice of medicine while reducing administrative burden. CMS is soliciting comments on eliminating this prohibition but again, is not officially proposing changes in the 2019 PFS proposed rule.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Best regards,
Kirk Reinitz, CPA 
President/CEO