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CMS may overhaul E/M coding; history (and exam) may be history

Brace for a big shake-up to E/M coding. CMS announced its intention to pursue “comprehensive reform of E/M documentation guidelines” in the 2018 proposed Medicare physician fee schedule released July 13.
Citing two elements of E/M coding as especially burdensome to providers – history and physical exam – CMS announced it would seek to embark on a “multi-year, collaborative effort” to revise current E/M guidelines.
CMS proposed the change in response to what the agency refers to as repeated calls from the provider community to update the 1995 and 1997 guidelines that steer E/M documentation, CMS seeks to “reduce clinical burden and improve documentation in a way that would be more effective in clinical workflows and care coordination,” states the proposed rule.
“We are seeking input from a broad array of stakeholders, including patient advocates, on the specific changes we should undertake to reform the guidelines, reduce the associated burden and better align E/M coding and documentation with the current practice of medicine,” states CMS.
Specifically, CMS seeks public comment on how to revise the history and physical exam components of E/M documentation. But the agency also opened the door to a more significant way of reporting E/M codes altogether.
“We are also specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels,” states the proposed rule.
The agency states that “medical decision-making [MDM] and time are the more significant factors” weighing on a given level of E/M service.
“As long as a history and physical exam are documented and generally consistent with complexity of MDM, there may no longer be a need for us to maintain such detailed specifications for what must be performed and documented for the history and physical exam,” states the agency.
Comments are due no later than Sept. 11. Once the rule is published, comments can be submitted through
Other notable provisions in the proposed fee schedule
  • Conversion factors trimmed. Next year’s conversion factor will have a little shaved off the top, as has been CMS’ practice since the Medicare Access and CHIP Reauthorization Act (MACRA) eliminated the sustainable growth rate. The proposed update factor of .50% for physician services will be cropped by .21%, resulting in a conversion factor of $35.9903, compared with this year’s $35.8887. Anesthesia providers start with the same update factor, but they could see a conversion factor of $22.0353, which is slightly lower than this year’s conversion factor of $22.0454, thanks to various cuts that add up to .55%.
  • Details revealed for Medicare Diabetes Prevention Program (MDPP). Last year, CMS proposed to allow non-provider "coaches" to bill Medicare for educating pre-diabetics would undergo several important changes under the proposed rule, most of them encouraging to entrants:
  • MDPP suppliers start enrolling Jan. 1. New entrants who aren't enrolled providers have been expected to enter the program as suppliers, and Medicare proposes to allow them to enroll starting on the first of the year. Their enrollment process would be separate from that of regular Medicare suppliers.
  • Delayed start from Jan. 1 to April 1.
  • Virtual program limited. An all-online virtual MDPP had been floated, but now CMS proposes to only allow a live/online hybrid.
  • "Interim preliminary" status added. Centers for Disease Control and Prevention (CDC) recognition of a program is a condition of participation, but CMS proposes to add its own "interim preliminary recognition" to "bridge the gap until any CDC preliminary recognition standards are established."
  • Participants who become diabetic can stay: Though the program is for pre-diabetics, under the proposed rule, if they become diabetic under care, they can stay in the program.
  • Three-year limit: Previously it was proposed that qualifying participants could stay in the program indefinitely, but the rule proposes a two-year limit on "maintenance" visits -- making the program with its one-year "core" program a three-year program.
  • Pay for (participant) performance: After initial sessions, programs get increased payments if participants hit weight loss targets under the proposed rule.
  • Beneficiary "incentives." CMS proposes to allow items and to be "furnished as in-kind beneficiary engagement incentives" during an "engagement incentive period" to encourage sign-up and attendance.
  • The rule previews 74 new services. The proposed physician fee schedule includes an early look at services that will be included in your 2018 CPT and HCPCS II manuals. The majority of the services – which are listed with a placeholder code and a full descriptor – are scattered throughout the CPT manual. New services include: seven E/M codes, five anesthesia codes, five nasal/sinus endoscopy codes, eight endovascular repair codes, seven radiology codes and six medicine codes. The proposed rule also contains seven new services that will be reported with HCPCS codes, which will include insertion and removal of non-biodegradable drug delivery implants and prolonged preventive services.
  • Some provider-based outpatient departments could see facility rates cut in half. CMS is proposing to set payments for certain services performed by non-exempt off-campus provider-based departments at 25% of the hospital outpatient prospective payment rate next year, down from 50% this year.
  • Some potentially misvalued codes may get a boost. CMS is wondering whether to review emergency department visits (99281-99385) as undervalued “given the increased acuity of the patient population and the heterogeneity” of ED locations, such as free-standing and off-campus emergency departments. The agency also proposes to review the value of sacroiliac joint arthrodesis (27279) as potentially undervalued and is seeking additional comment on the work value for dialysis vascular access codes 36901-36909. The agency proposes to evaluate the direct practice expense for flow cytometry codes 88184 and 88185 as no longer accurately capturing clinical labor and supplies.
  • CPT codes set to replace suite of G codes that debuted Jan. 1. As expected, new CPT codes – not yet finalized – will replace a number of G codes that CMS finalized for the 2017 reporting year. Expect to add new CPT codes to your reporting mix for a number of behavioral health services, including Collaborative Care Management codes (G0502, G0503, G0504), which will crosswalk to services listed under placeholder codes 994X1, 994X2 and 994X3, respectively; cognitive-assessment code G0505, which will crosswalk to 99XX3; the initiating visit code for chronic care management (CCM) (G0506), which does not yet appear to have a crosswalk; and general behavioral health integration code G0507), which crosswalks to 99XX5.
  • Appropriate use criteria (AUC) for imaging to start in 2019. Implementation of Medicare's proposed AUC Program for Advanced Diagnostic Imaging – under which ordering providers would have to consult specified applicable AUC using qualified clinical decision support mechanisms (CDSMs) when ordering applicable imaging services and furnishing providers would have to report that information to CMS on claims – was pushed back last year from a 2016 deadline. In this rule, CMS proposes to start requiring imaging providers to participate in an "educational and operations testing year" of AUC in 2019, during which providers would be expected to take part but would be paid whether or not they did.
  • Changes to Shared Services. CMS proposes to tweak operational features of this accountable care organization (ACO) program -- for example, adding new chronic care management (CCM) and behavioral health integration (BHI) codes to its definition of primary care services under the program and assigning beneficiaries based on service supplied at rural health clinics (RHCs) or federally qualified health centers (FQHCs).
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