Big Changes Proposed for Evaluation and Management Services

It’s been more than 20 years since the 1997 revisions to Evaluation and Management guidelines, which focus mainly on physical examination. The 2019 proposed changes provide practitioners a choice in the basis of documenting E/M visits; alleviating the burdens and focusing attention on alternatives that better reflect the current practice of medicine. The implementation of electronic medical records has allowed providers to document more information, yet repetitive templates, cloning and other workflows have pushed the envelope on compliance in documenting the traditional elements of the visit.

The proposed changes to Evaluation and Management were released in the Federal Register on July 27. The Center of Medicare and Medicaid Services is taking comments until Sept. 10, before releasing the Final 2019 Medicare Fee Schedule.

The CPT guidelines are not changing! The American Medical Association is the author of the CPT books, and there is no change in the 1995 or 1997 guidelines for E/M documentation. Medical necessity remains the overarching criteria to select a level of service. There are three proposals to reduce documentation burdens related to CMS:

Proposal One

Simplify History and Exam Documentation, allowing the physicians to focus on changes in health and allow ancillary staff to document chief complaint and history without the physician re-entering it.

Proposal Two

Remove History and Exam from E/M level decision. Currently, history and exam are two of three required elements along with medical decision-making. Medical decision-making would be the sole determinant of E/M level. Providers could use face-to-face time as a determining factor when selecting an E/M service level.

Proposal Three

Pay a single rate for Level E/M visits for the reduced burden in documentation and coding guidelines. Proposals one and two will be a package deal in proposal three. The tables below reflect the proposed payment rates.

Table A – New Patient E/M: Non-facility

Code        2018 Payment Rate     CY 2018 New Payment Rate

Table B – Established Patient E/M: Non-facility

Code           2018 Payment Rate             CY 2018 New Payment Rate

There are two add-on codes proposed, including one for primary care to cover inherent complexity. The primary care add-on code is GPC1X. It can only be utilized by primary care. By adding the G code to Medicare claims, internal medicine and family practice can actually earn up to five percent more revenue and reduce documentation efforts.

The add-on code available to a list of ten specialties is GPC0X. The specialties were chosen due to the inherent complexity related to E/M. The specialties eligible for this add-on code are: endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology or interventional pain. The big loser in this proposal is pulmonary medicine, with a reduction of 6.2 percent in revenue projected by Part B News. The big winner is urology, with a projected increase in revenue of 22 percent with the add-on code.

As a certified coder, I believe the reduction in documentation is a positive change. Most physicians were not educated on CPT coding as part of their clinical training. Physicians want to be compliant, but the guidelines are too complex to analyze during each encounter. The ancillary staff should be trained to effectively gather pertinent information to support the physician. This would allow physicians to focus on the clinical needs of the patient. CMS expects medical necessity to prevail and each encounter to stand alone in relation to the full medical record.

A proposal for 2019, we aren’t hearing about is an E/M multiple procedure payment adjustment related to duplicative resource costs when an E/M is visited and a procedure with global periods are furnished on the same day. CMS would reduce the E/M payment by 50 percent.

Administrators should review the proposed options for documentation to understand the effect on their practice. If your practice has the potential to see a negative adjustment without the option to utilize an add-on code, you should analyze the E/M dispersion pattern to understand the financial impact to your practice. For the most part, the proposed changes are positive in an effort to reduce the burden of redundant documentation. We should continue to hear much more information regarding this game-changing proposal particularly after the comment period ends on Sept. 10. The final 2019 fee schedule will be released around the first week of November. Stay tuned!

If you would like to send a comment to CMS on these changes (and we suggest you do), go to https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official partner with the Medical Association.