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CMS proposes sweeping changes to E/M payments, documentation requirements

You could find a single payment amount for your level 2 to 5 office codes and significantly reduced documentation requirements as soon as Jan. 1 should changes put forth in the 2019 proposed Medicare physician fee schedule come to realization.
Among the various proposals aimed at streamlining E/M reporting, CMS seeks to create a single payment of $93 for established patient codes 99212-99215 that would replace distinct pay rates for each of the four codes. That rate, in 2018 dollars, is roughly smack in the middle of payments for 99213 ($74) and 99214 ($109). The rate is significantly lower than level 5 code 99215, which pays $148 this year.
CMS proposed a similar structure for new patient codes 99202-99205, which would be reimbursed at $135, regardless of the level of service. For the sake of comparison, 99203 currently pays about $110, and 99204 nets $167. Under the proposal, level 1 codes would have a separate payment similar to the current rates.
According to the proposed pay structure, some specialists stand to gain financially, while others would lose. Valuing levels 2 to 5 together would result in podiatrists gaining a net 12% increase in pay, according to estimates in the rule on current pay rates. Dermatologists would see a 7% boost, and orthopedic surgeons would gain 4%. Conversely, endocrinologists would face a 10% loss in overall revenue, and rheumatologists and neurologists would see a 7% loss each.
The agency is proposing Jan. 1, 2019, as a start date for its vast range of E/M proposals, including payments.
“My jaw is dropping,” says Betsy Nicoletti, president of Medical Practice Consulting in Northampton, Mass., after reviewing the proposed payment structure.
Documentation requirements get flexible
CMS justifies the streamlined payments by noting proposals for streamlined documentation.
“We believe that the coding, payment and documentation requirements for E/M visits are overly burdensome and no longer aligned with the current practice of medicine,” CMS states in the proposed rule.
You could banish the 1995 and 1997 guidelines entirely should one of CMS’ proposals become standard operating procedure. Calling the current guidelines “administratively burdensome and outdated,” the agency floats the idea to let providers use medical decision-making as the sole element to support an E/M service, relegating history and exam to the dustbin.
Alternatively, providers could turn to time as the key element and dismiss the rest of the elements entirely. Or, CMS says, providers could elect to stick with the current guidelines.
“This would allow different practitioners in different specialties to choose to document the factor(s) that matter most given the nature of their clinical practice,” the proposed rule states.
CMS offered two other proposals on which it is seeking feedback: Providers could continue to report on the history and exam elements but only note what has changed or they could “verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it,” states a proposed rule fact sheet.
The coding structure itself will remain, CMS says.
Other proposed E/M changes
  • Pay may be cut for same-day E/M visits, procedures: CMS proposes to apply a multiple-service payment adjustment when an E/M visit is reported the same day as a procedure, similar to the long-standing multiple-procedure payment reduction for surgical and some imaging services. Under the proposal, when an E/M is reported on the same date as a procedure, Medicare would reduce payment by 50% for the least expensive service provided. In some cases, it could be the E/M service – for example, if reported with a higher-valued procedure such as an injection. In other cases, the reduced payment could be for the procedure, such as an EKG. The proposal appears to apply to office-based services, when modifier 25 would be appended to the E/M code.
  • CMS proposes add-on G codes for primary care. CMS proposes a primary care-specific G code that providers could attach to E/M encounters and that would “more accurately account for the type and intensity of E/M work performed in primary care-focused visits,” the rule states.
The agency expects that the code would get widespread use. “As this add-on G-code would account for the inherent resource costs associated with furnishing primary care E/M services, we anticipate that it would be billed with every primary care-focused E/M visit for an established patient,” CMS states. Currently, proposed payment rates are unclear.
As proposed, the dummy code reads as follows: GPC1X (Visit complexity inherent to E/M associated with primary medical care services that serve as the continuing focal point for all needed health care services [Add-on code, list separately in addition to an established patient evaluation and management visit]). The code would be assigned 0.07 work RVUs. “This proposed valuation accounts for the additional work resource costs associated with furnishing primary care that distinguishes E/M primary care visits from other types of E/M visits and maintains work budget neutrality across the office/outpatient E/M code set,” CMS says.
  • Specialists get a G code, too. CMS doesn’t intend to leave specialists out when it comes to add-on G codes for E/M encounters. Designed for “specialty professionals for whom E/M visit codes make up a large percentage of their overall allowed charges,” CMS created the following add-on: 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 established patient evaluation and management visit]). CMS would assign 0.25 work RVUs to the code.
Quality Payment Program (QPP) changes
CMS made a series of tweaks to the QPP, including to the merit-based incentive payment system (MIPS).
  • Scoring changes. Quality is reduced from 50% of total MIPS score to 45%, cost rises from 10% to 15%, improvement activities stays at 15% and promoting interoperability, renamed from advancing care information, stays at 25%. Providers will still need to report at least six quality measures including at least one outcome measure, with exceptions. Data completeness threshold is still 60%.
  • Measure changes. The rule proposes adding 10 new quality measures including “Continuity of Pharmacotherapy for Opioid Use Disorder” and “HIV Screening” and removing 34 quality measures including “Chlamydia Screening and Follow-up” and “Preventive Care and Screening: Body Mass Index [BMI] Screening and Follow-Up Plan.” Some measures are being altered – for example, for the promoting interoperability category, the “Send a Summary of Care” measure is being changed to “Support Electronic Referral Loops by Sending Health Information.” 
  • Performance periods will remain a full year for quality and cost and 90 days for improvement activities and promoting interoperability.
  • New low-volume threshold category. CMS proposes to stick with the 200-patient, $90,000 allowed charges for low threshold from last year, but also exempt providers with “200 or fewer covered professional services furnished to Part B-enrolled individuals.” Low-threshold-exempted providers can also “opt in” to participate voluntarily in MIPS if they exceed at least one of the three low-volume threshold criteria.
  • “A single MIPS determination period” is proposed for determining MIPS eligibility, as opposed to the divergent timeframes currently used for different kinds of clinicians and groups.
  • New providers eligible for MIPS. CMS will consider adding qualified speech-language pathologists, qualified audiologists, certified nurse-midwives, registered dietitians and nutrition professionals to MIPS as soon as the measures changes are finalized and they can tell whether these providers would have enough measures to report.
Other notable proposals in the rule
  • Expect 81 new procedure codes in 2019. Your 2019 CPT manual will contain 69 new codes that are billed under the physician fee schedule, according to table 13 of the proposed rule. The new procedure codes include fine needle aspiration and skin biopsy; insertion, replacement and removal of cardiac monitors; replacement of gastronomy tubes; elastography; electronic analysis of cranial nerve and brain neurostimulators; psychological and neuropsychological testing; and interprofessional referral and consulting services provided by phone, internet or electronic health record. Your new HCPCS level II manual will contain 12 new codes if CMS institutes all of the proposals, including two add-on codes that will reflect the complexity of E/M visits based on specialty; two codes for E/M visits performed by podiatrists and a code for a brief “virtual check-in.”
  • Conversion factors increase. The 2019 conversion factor would inch up to $36.0463 from this year’s $35.9996. The 2019 anesthesia conversion factor would be $22.2986, up from this year’s $22.1887.
  • Part B drug payment drops to ASP+3%. After years of adding 6% to the average sales price (ASP) of Part B drugs, the rule proposes a knock-down in what the beneficiaries pay for the drugs to ASP plus 3%, “recommended based on statements made by industry, MedPAC’s analysis of new drug pricing, and OIG data,” the rule states.
  • Joint replacement codes may be up for revaluation. Total hip arthroplasty (27130) and total knee arthroplasty (27447) have been nominated for revaluation as potentially overvalued codes by an unnamed member of the public, who submitted the codes under Medicare’s potentially misvalued codes provision. Also on the list, two gastroenterology procedures, CT head scan, a complete EKG (93000) and complete echocardiogram with Doppler (93306). “The submitter suggested that the times CMS assumes in estimating work RVUs are inaccurate for procedures, especially due to substantial overestimates of preservice and postservice time, including follow-up inpatient and outpatient visits that do not take place,” CMS states in the proposed rule. CMS will evaluate the supporting documentation for the nominations to assess whether the codes meet the criteria for misvaluation. The agency will announce in the 2020 proposed fee schedule whether it will formally propose those codes for revaluation, giving the public an opportunity to comment on them.
  • New payments for non-face-to-face services using technology. CMS proposes to provide a small payment for “brief check-in services” in which a physician uses “communication technology” to determine whether an established patient needs an office visit. Now, if a patient calls and the physician determines that no visit is warranted, that service is unpaid. CMS wants to hear what kinds of communication technology are used to provide those services.
The service would have a 0.25 work relative value unit (RVU) and be described with a dummy code GVCI1 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion).
  • e-Consults between providers tweaked, shifted to A status. In addition to covering the two new interprofessional codes, CMS intends to shift codes 99446-99449 from bundled to active status next year. The codes’ descriptors have been revised to add electronic health records to the list of communication methods, according to the proposed rule.
  • Participation in CMS’s global surgery data-collection effort varies by specialty and location. In the last six months of 2017, CMS says more than 32,500 providers in nine states reported 990,581 post-operative visits using code 99024. As finalized in the 2017 physician fee schedule, practices of 10 or more clinicians in the selected states were to report the non-payable post-operative visit code for follow-up care provided for 293 high-volume 10- and 90-day procedures. The top specialties reporting 99024 included surgical oncology (92% reporting rate), hand surgery (90% reporting rate) and orthopedic surgery (87% reporting rate). Top three states: North Dakota (56%), Ohio (49%) and Florida (49%). CMS will use the data collected from the effort to assess whether the surgical codes’ post-operative care valuation is accurate. The 99024 survey collects data strictly on the number of visits, CMS notes. The agency plans to launch a separate effort to collect data on the level of post-op visits, including time, staff and activities involved in furnishing post-operative visits and non-face-to-face services.
  • Therapists could see end of functional status G-code reporting but new modifiers for PTAs, OTAs. CMS proposes to sunset the six-year requirement to report unpaid functional status G-codes at the end of this year. CMS was supposed to use data from the codes to reform payment for outpatient therapy services, but that effort isn’t necessary now that Congress has permanently repealed the therapy caps and installed new protections for the services, the agency says. Meanwhile, the agency proposes to introduce new modifiers to report when physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) perform the services “in whole or in part.” That’s because those services must now be paid at 85% of the Medicare allowable rate, based on the Bipartisan Budget act of 2018 – the same law that repealed the therapy caps.
  • CMS proposes a Medicare Advantage MIPS demo. Called the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration, under this demo, providers who “participate sufficiently in Medicare Advantage (MA) arrangements that are similar to Advanced APMs” via their Medicare Advantage Organziation (MAOs) may not have to participate in regular MIPS. CMS Administrator Seema Verma said this was part of CMS’ effort to provide a “more level playing field” for MA providers and organizations.
Subscribers: Check upcoming issues of Part B News for more details on the proposed physician fee schedule and QPP.
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