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Massive E/M changes slow down as CMS gives practices greater prep time

CMS hit the brakes on making imminent changes to the oft-used E/M code set that’s tied to billions of dollars in medical practice revenue. Streamlined payment rates are off the table for 2019, as are vast documentation revisions, according to the 2,378-page final 2019 Medicare physician fee schedule released Nov. 1. Once you’ve read through our detailed breaking news, take our quick, confidential survey to share your opinion.
That doesn’t mean changes aren’t coming Jan. 1 – or beyond. The federal agency plans to weave a number of smaller updates into the E/M payment and documentation picture in 2019 and will implement a broader array of changes in 2021, including a single-rate payment structure for established codes 99212-99214 and new-patient codes 99202-99204.
However, following up on a proposed rule that left many in the medical practice profession holding their breaths, CMS backed off on many of its ire-inducing proposals that would have drastically reshaped how it pays for and assesses the accuracy of E/M services.
“Commenters largely objected to our proposal to eliminate payment differences for office/outpatient E/M visit levels 2 through 5 based on the level of visit complexity,” CMS states in the final rule. Many commenters said they would experience pay cuts and generally let the agency know that the “aggressive” launch date that CMS proposed for Jan. 1, 2019, was far too fast.
Instead, in 2019 and 2020, CMS will maintain separate payments for each distinct E/M code. Practices also will continue to use the current 1995 and 1997 documentation guidelines to guide their way. In a related case of standing-pat, podiatrists will not be singled out with a separate E/M reporting structure. In other words, it’s largely business as usual.
However, take note of some meaningful changes that CMS will adopt starting Jan. 1:
  • For E/M visits, providers will not be required to re-enter information about the patient’s chief complaint and history that a staff member has already entered. Instead, the provider can indicate in the medical record that the information has been “reviewed and verified,” CMS says.
  • For established office visits, providers can focus their documentation on changes since the last visit and “need not re-record the defined list of required elements if there is evidence” that the provider has already done so, an accompanying CMS fact sheet states.
  • For home visits, providers will no longer be required to prove explicit medical necessity when reporting the range of codes 99341-99350.
The agency believes these measures will provide “immediate burden reduction,” something it has emphasized in recent rulemaking periods.
What it means for providers
For medical practices, changes to E/M services can have a big effect on financial health. E/M encounter codes for established patients make up a huge source of revenue for physician practices. In 2017, medical groups gained more than $13 billion on claims for 99211-99215. About 80% of that revenue is tied to just two codes – 99213 and 99214 – which account for most patient visits.
Many commenters called on CMS to take a more cautious approach, and CMS ultimately agreed.
“A delayed implementation date for our documentation proposals would also allow the AMA time to develop changes to the CPT coding definitions and guidance prior to our implementation, such as changes to MDM [medical decision-making] or code definitions that we could then consider for adoption,” CMS states. “It would also allow other payers time to react and potentially adjust their policies.”
The outlook beyond 2020
Despite a two-year slowdown, CMS anticipates going full-throttle into 2021 with a series of major revisions to E/M coding, payments and documentation requirements.
The agency plans to rekindle its approach to single-rate payments, although it will excise highest-level codes 99205 and 99215 from the flattened fees. Instead, the pay rates will bundle levels 2 through 4 codes into a to-be-determined payment amount. The level 5 codes will be left alone “to better account for the care and needs of complex patients,” CMS states. A fact sheet for E/M payment amounts shows you what your payments might look like with and without various add-on codes.
Documentation changes also will plow ahead. Starting in 2021, practices will be able to opt for medical decision-making or time as the key documentation requirement when reporting E/M office codes. CMS plans to adopt a minimum documentation standard for the middle-of-the-pack, levels 2 through 4 codes.
The add-on codes that CMS had proposed also are set to return in 2021; however, they’ll be limited to levels 2 through 4 codes. And practices will be able to tap into an “extended visit” code to account for high-duration encounters that correspond to a level 2 through 4 visit.
E/Ms and modifier 25
CMS won’t implement a proposal to apply a 50% multiple-service reduction when an E/M visit is reported the same day as a minor surgical procedure. The agency backed off that proposal after commenters warned it would give physicians incentive to fragment their care and bring patients back for visits on a different day to avoid the payment reduction. That “could create a significant undue burden for beneficiaries,” the agency states. CMS says it will continue to look for ways to address what it views as “duplicative resource costs” for same-day E/Ms and procedures but will do it “in ways that will protect Medicare beneficiaries’ access to appropriate care,” the rule states.
Quality Payment Program changes
More types of providers will have to participate in the Merit-based Incentive Payment System (MIPS) of the Quality Payment Program (QPP). In 2019, physical therapists, occupational therapists, clinical psychologists, speech-language pathologists, audiologists, registered dietitians and nutrition professionals are eligible for the program. CMS had proposed including clinical social workers and nurse-midwives, but those types didn’t make the cut.
Small practices get some breaks in the 2019 QPP. Practices with 15 eligible clinicians (ECs) or fewer get a six-point bonus automatically in the Quality category. In addition, those practices still will be able to report Quality measures via claims. Starting in 2020 while larger practices get zero points for measures that do not meet data completeness – that is, that do not represent the required 60% of their patients for the period – measures submitted by small practices will continue to receive three points even if they don’t hit that target.
Also, small practices may be excused from the program if they can’t meet at least one of three criteria –$90,000 or less in Part B allowed charges for covered professional services; 200 or fewer Part B-enrolled beneficiaries; or 200 or fewer covered professional services under the fee schedule. But those who meet at least one of these criteria may opt in if they want.
As proposed for MIPS, 10 measures – four process-related, four patient-reported outcome and two patient-reported process measures – will be added to the Quality category; 26 measures were removed, as opposed to the 34 proposed to be deleted.
For 2019, participants must choose from nine Promoting Interoperability measures, complete six and also finish two bonus measures. Six new Improvement Activities are added, including “Comprehensive Eye Exams” and “Financial Navigation Program.”
Cost performance will be measured on total per capita cost versus Medicare spending per beneficiary as derived from Medicare claims. Participants also will have their Cost performance counted against eight new episode-based measures if they are attributable in any of 10 or more procedural episodes, such as Elective Outpatient Percutaneous Coronary Intervention (PCI), or 20 or more acute inpatient medical condition episodes, such as Simple Pneumonia with Hospitalization.
Quality is 45% of your score in 2019, cost 15%, Promoting Interoperability (the former Advancing Care Information) 25% and Improvement Activities 15%. The performance threshold to fulfill MIPS is 30 points; the additional performance threshold to be eligible for a bonus is 75 points.
The Advanced Alternative Payment Model (APM) alternative to MIPS gets a little tougher in some ways – for example, at least 75% of clinicians in the APMs must use up-to-date certified electronic health records technology (CEHRT), up from 50% this year. The revenue-based nominal amount for entry into the program will remain at 8% through 2024.
Other notable policies
  • Providers will see a slight bump to the conversion factor – up to $36.0391 in 2019 from $35.9996 in 2018 – for physician services. Anesthesia providers will see the conversion factor for anesthesia services go up to $22.2730 in 2019 from $22.1887 in 2018.
  • Prepare for new non-face-to-face codes. If your practice intends to offer the new mini patient encounters, make sure everyone remembers this formula: seven days, 24 hours or the soonest available appointment. Next year, CMS will cover virtual check-ins (G2012) and remote evaluations of pre-recorded patient information, such as a photo or video (G2010). CMS acknowledged that changes in technology and the expectations of patients and providers meant that payment formulas that bundle all related clinician/patient interactions into an E/M service was short-changing practitioners. However, CMS emphasized that it will monitor the services for overutilization. Here are a few requirements to keep in mind:
  • The purpose of the services is to determine whether the patient needs an in-person visit.
  • The service can’t be related to an E/M visit that occurred up to seven days before the check-in or evaluation.
  • The service can’t lead to an E/M visit within 24 hours or the earliest available appointment.
  • The services are for established patients.
  • The patient must consent to each service.
  • The service must be performed by the clinician who will bill for the service. A medical assistant couldn’t take a phone call for a virtual check-in. A registered nurse could not make the follow-up phone call for a remote evaluation. In addition, the services must be performed by a clinician who can report E/M services.
  • The follow-up portion of G2010 may be performed by phone or HIPAA-compliant electronic methods such as e-mail, text messaging or patient portal.
  • When a clinician can’t perform an evaluation because of the quality of the image or recording, the practice can’t bill for G2010.
  • Interprofessional consults and referrals will be covered. CMS will go ahead with its plan to cover consults that are performed via phone, internet or electronic health record (EHR). That includes four codes that were introduced in 2014 (99446-99449) and two that will be new in 2019 (99451-99452). Those are time-based codes, and you should check your 2019 CPT manual for the reporting rules for the services. However, practices should note that the practice must get the patient’s consent for each consult and referral.
  • Joint replacement codes to be reviewed for possible revaluation. CMS is adding total hip arthroplasty (27130) and total knee arthroplasty (27447) to its list of potentially overvalued codes that will be reviewed by the AMA’s Relative Value Update Committee (RUC). Also on the list, two gastroenterology procedures (43239 and 45385), CT head scan (70450), a complete EKG (93000) and complete echocardiogram with Doppler (93306). The agency declined to add two other nominated cardiovascular codes (92992 and 92993), which are currently contractor-priced because the RUC intends to take up the valuation of those codes.
  • Therapists see the end of functional status G-code reporting but the start of new modifiers for physical therapy assistants (PTAs) and occupational therapy assistants (OTAs). CMS will 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. However, providers will have two new modifiers to report when PTAs and OTAs perform more than 10% of the services: CQ (Outpatient physical therapy services furnished in whole or in part by a physical therapy assistant) and CO (Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant). 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. Those modifiers won’t be required until 2020. – DecisionHealth staff (
What do you think of the final rule? Let us know in this very short, confidential survey.
Editor’s note: Get every last detail on E/M changes and more from the final 2019 Medicare physician fee schedule with the one-hour webinar 2019 E/M Forecast: Prepare Your Practice for Fee-Schedule Changes on Nov. 28. Register at
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