Final physician fee schedule watch: We're all waiting to see what CMS does with E/M

by Julia Kyles, CPC on Oct 26, 2018

By this time next week, we should know the answer to a question that has been on the minds of health care stakeholders since July:

What in the world will CMS do with E/M visits?

The topic was of great interest to attendees of both the anesthesia and the pain management conferences during last week’s Advanced Specialty Coding Symposium. In particular, people wondered if CMS really would go ahead with its plan to flatten the fees for new and established office visits (99202-99205 and 99212-99215).

The proposed 2019 Medicare physician fee schedule certainly gained a lot of attention if the 15,316 published comments are anything to go by. The 2018 proposed rule netted 1,619 comments.

A glance through the comments indicates that the E/M proposals that involve cutting revenue are not popular, even though CMS has talked up the burden-reduction elements of the changes.

I vigorously oppose the proposed major decrease in payment reimbursement. Most primary care doctors only survive because of being able to bill a level 4 visit. Take this away, and even more docs will be put out of business, and more people will lose their doctor. Or their doctor may only see them for one problem at a time, thus delaying vital care. Do not eliminate the code 5 option. Physicians and APNs *really do* provide that level of complex care, and they should be reimbursed for it!

The threat of doctors seeing patients for one problem at a time is a common refrain in the comments. As were complaints about the proposal to cut payments when a provider uses modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to bill an E/M visit and a procedure for the same patient on the same day.

Abandon this proposal to reduce reimbursement by 50% for the least expensive component(s) of an encounter when modifier 25 is appropriately used. This is based on flawed assumptions and would lead to significant reductions in reimbursement that could negatively impact providers’ ability to serve patients.

The comments on proposed coverage of virtual visits and remote consults and referrals were generally supportive, and more measured. The majority of comments that mentioned the codes were prepared comments that covered several aspects of the rule and were submitted by one or more members of an organization. However, an individual submitter identified an interesting reason to use remote, pre-recorded service – control of infectious diseases:

GRAS1 [Remote evaluation of recorded video and/or images submitted by the patient] has tremendous potential to support public health efforts focused on reducing the transmission of infectious diseases, such as emerging pathogens, like Zika virus, Ebola virus and multi-drug resistant tuberculosis (TB). While new pathogens get much attention, diseases such as TB are often medically mismanaged or overlooked altogether. Clinical expertise is often concentrated in urban areas, leaving TB patients in rural areas without expert clinical care.

Curing TB requires adherence to a multidrug regimen for a minimum of 6 months and for as long as 24 months. Failure to take the medications as prescribed can lead to treatment failure, drug resistance and further spread of TB, resulting in morbidity and death for the patient and a threat to public health. Treatment failure is a leading contributor to the emergence of drug-resistant TB, which increases the duration of therapy, increases the cost of health care, and often leads to outcomes that are less than optimal. The consequences of non-adherence to TB treatment led to the implementation of directly observed therapy (DOT) in the 1990s, a program that has since become the standard of care in Ohio and across the US. While DOT is a best practice, it is labor intensive, expensive and can be a barrier to effective therapy in many parts of the U.S.

GRAS1 could allow for DOT, or observed dosing, the suggested standard of care suggested by the Centers for Disease Control and Prevention (CDC) and the American Thoracic Society, to be implemented across the nation, supporting public health efforts to prevent and control the spread of TB.

CMS should be commended for not limiting this code to a particular illness or geographic location.

It’s impossible to predict what CMS will do, but the final rule is at the Office of Management and Budget and we’ve been checking the site regularly because once a rule is taken off the site it is usually published quickly after. If you want to keep an eye on the rule's progress, you can filter results down to HHS and then select Final from the pie chart on the right. Or you can keep checking the blog. We’ll have complete coverage of the final rule, including QPP 2019, soon after the final rule is released.

Blog Tags: CMS, E/M services, fee schedule