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E/M Code Changes: A Deeper Dive at What Could be Coming for 2021

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E/M Code Changes: A Deeper Dive at What Could be Coming for 2021

This is the second in a series of articles reviewing notable changes in the 2019 Physician Fee Schedule Final Rule and provides a deeper discussion of the potential changes to the E/M Coding regime scheduled to take effect in 2021. For the original article, please see Evaluating and Managing the E/M Codes for 2019 and Beyond.

Brief Recap

The Centers for Medicare and Medicaid Services proposed some major changes to the way Evaluation and Management services are reimbursed in the 2019 Physician Fee Schedule Proposed Rule. The PFS Final Rule[1] adopted some of the proposed changes but scheduled them to take effect in 2021. The commentary on these proposals and CMS’s responses in the PFS Final Rule provide some valuable insight into what CMS is trying to accomplish with the E/M reimbursement changes and what these changes might ultimately look like when made effective in 2021.

Proposals for 2021

Collapsing Reimbursement for Levels 2-4.  CMS has proposed to collapse the reimbursement for E/M level 2 through level 4[2] codes into a single reimbursement amount for office/outpatient settings. To come up with this combined payment rate, CMS is taking the average of the current inputs for determining E/M reimbursement (work RVUs, direct PE inputs, time, and specialty mix) for level 2 through 4 E/M codes, weighted by the frequency with which each code is currently billed (based on the most recent five years of utilization data). For an example of what this new reimbursement structure might look like, see Table 19 and Table 20 below (excerpted from the Final Rule), which compare the 2021 E/M reimbursement methodology to the current methodology for both new and established patients in terms of 2018 dollars:

As you might expect, this new reimbursement structure will likely result in a reduction in overall reimbursement for many physicians who ordinarily bill higher level E/M codes. Fortunately, CMS is proposing new add-on codes (to be billed only with the combined level 2 through 4 visits) with additional reimbursement which should mitigate some of the effects of the new E/M reimbursement structure.

Add-On Codes.  CMS finalized its proposal for new add-on codes to account for primary care and particularly complex visits, as well as extended visits associated with E/M services. CMS indicated that there should not be any additional documentation requirements for these add-on codes (for the most part)[3] and that information already captured on the claim form should suffice to show that the E/M service provided was for primary care.

Primary Care Add-On Code.  CMS proposed an add-on code (GPC1X) to be appended to claims for primary care E/M services. Notably, the add-on code only applies to face-to-face time with patients[4], and it cannot be appended to a global procedure code that encompasses E/M services. CMS expects this add-on code to be used predominantly by primary care practitioners (e.g., family medicine, internal medicine, pediatrics, and geriatrics), and in fact, indicated that this add-on code would likely be billed for almost all office/outpatient-based E/M services provided by these practitioners. However, CMS also noted that some specialists also function as primary care practitioners (e.g., OB/GYN or cardiologist) and may be able to utilize this add-on code.

Add-On Code for Specialty Professionals with Large E/M Volume.  CMS also proposed an add-on code (GCG0X) for certain specialties which perform mostly high-level (4 or 5) E/M services (rather than procedures) involving “non-procedural approaches to complex conditions that are intrinsically diffuse to multi-organ or neurologic diseases.” CMS originally included certain specialties[5] in the descriptor for this add-on code but has noted that several appropriate specialties[6] were omitted and that the appropriate reporting of this add-on code “should be apparent based on the nature of the clinical issues addressed at the E/M visit, and not limited by the practitioner’s specialty.” CMS also noted that there may be some rare instances where both the primary care add-on code and the specialty professional add-on code could be billed for the same service (provided all the requirements for both codes are met in a single E/M visit).[7]

Extended Visit Add-On Code.  There is also an add-on code (GPRO1) to account for additional resources utilized when physicians have extended visits with patients. This code may be billed if the practitioner spends between 34 and 69 minutes (for established patients) or 38 and 89 minutes (for new patients) of face-to-face time with the patient, regardless of which level (2, 3, or 4) E/M code was reported. Providers will have to note the amount of time spent face-to-face with the patient in order to bill for the extended visit code.

Choice of Documentation Method.  The current (1995 or 1997) E/M documentation guidelines[8] are based on three factors (all of which must be documented): History or Present Illness, Physical Examination, and Medical Decision Making (MDM). Starting in 2021, practitioners will have the option to document E/M services using any one of the following documentation methods: (1) the current (1995 or 1997) guidelines; (2) MDM only; or (3) time only. If practitioners decide to use the existing guidelines or the MDM-only documentation approach, they would only need documentation consistent with the current level 2 E/M service in order to be reimbursed the combined amount for level 2 through 4 E/M services,[9] or consistent with the level 5 documentation requirements where a level 5 E/M code is billed. For practitioners using time as the documentation method, the practitioner must document face-to-face time personally spent with the patient at least equal to the typical time associated with the applicable level of E/M Code.[10]

Regardless of which documentation method practitioners choose, they must still be diligent in documenting medical necessity, as CMS noted several times in the Final Rule that medical necessity would have to be documented in the record regardless of the documentation method the provider chooses. Based on CMS’s comments in the Final Rule, practitioners may expect additional opportunities to comment on the allowable documentation methods in the coming years before the policy is finalized in 2021.

Conclusion

If these proposals move forward over the next several years, it appears there will be substantial disruption not only in how E/M services are reimbursed, but in how they are documented and billed. It is unclear whether these proposals will achieve CMS’s goal of reducing the administrative burden on practitioners, as the proposals simplify E/M coding in some respects and complicate it in others. Either way, practitioners should have the opportunity over the next two years to continue to comment on these proposals in an effort to have CMS modify or refine them before they go into effect in 2021.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

 

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] CMS originally proposed to collapse the reimbursement for E/M level 2 through 5 services into a single reimbursement amount but for now has decided to keep a separate reimbursement amount for level 5 E/M services to “better account for the care and needs of particularly complex patients.”

[3] For instances where the billing of the appropriate add-on code is not as readily apparent based on the information on the claim form, practitioners should consider additional documentation in the medical record to support the billing of the add-on codes.

[4] There are already add-on codes for non-face-to-face time, such as CCM and BHI codes.

[5] Endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/GYN, allergy/immunology, otolaryngology, cardiology, or interventional pain management.

[6] Nephrology, psychiatry, pulmonology, infectious disease, and hospice and palliative care medicine.

[7] CMS provides an example of a cardiologist in a rural area who provides care for complex cardiac conditions as well as primary care in his or her clinical practice. If the cardiologist provided both primary care services and specialty cardiology services in a given E/M visit, both GPC1X and GCG0X could be billed for the visit.

[8] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[9] For example, under the current guidelines, the practitioner must document: (1) a problem-focused history that does not include a review of systems or a past family or social history; (2) a limited examination of the affected body area or organ system; and (3) a straightforward MDM measured by minimal problems, data review, and risk (two of these three). By contrast, a practitioner using the MDM-only method would only have to document straightforward MDM measured by minimal problems, data review and risk (two of these three).

[10] This approach is consistent with the current policy guidelines that time can only be used as the applicable documentation method for E/M codes where counseling and/or coordination of care accounts for more than 50% of the face-to-face time between physician and patient. The typical time associated with a service or procedure is maintained in the AMA CPT codebook.

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Evaluating and Managing the E/M Codes for 2019 and Beyond

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Evaluating and Managing the E/M Codes for 2019 and Beyond

Editor’s Note: This article is the first in a series of articles about notable changes in the 2019 Physician Fee Schedule Final Rule.

In the 2019 Physician Fee Schedule (“PFS”) Proposed Rule, the Centers for Medicare and Medicaid Services (“CMS”) proposed some major changes to the PFS, including changes to the way Evaluation and Management (“E/M”) services are reimbursed. The PFS Final Rule[1] contains some good news and bad news. The good news . . . CMS isn’t making any of the major changes it proposed in 2019. The bad news . . . they plan on making some big changes over the next few years.

<<Quick Summary: 2019 Medicare Physician Fee Schedule and Quality Payment Program Final Rule>>

Proposal

CMS proposed to collapse several levels of E/M Codes into one reimbursement level with add-on codes for certain prolonged or complex visits.

Final Rule

CMS is reducing some documentation redundancies for 2019, but it is not finalizing most of the payment proposals described above until 2021.

The Details

Currently, there are 3 to 5 levels of E/M codes depending on the practice setting (3 to 4 in facility settings and 5 for outpatient or office settings). These codes are billed based on the relative complexity of the E/M service provided, as determined in accordance with either the 1995 or 1997 guidelines issued by CMS.[2] The higher the level of E/M service (and associated relative time and resources required to deliver those services), the higher the reimbursement. According to CMS, E/M codes represent approximately 40 percent of allowed charges for PFS services, and outpatient/office visit E/M codes represent about 20 percent of total PFS allowed charges. Despite the frequency with which E/M services are performed and billed, there are a number of complexities surrounding how they are billed and the documentation required for each level of E/M code.

In an effort to alleviate this burden, CMS proposed to collapse the reimbursement for E/M level 2 through level 5 codes into a single reimbursement amount. In addition, CMS proposed to allow two new add-on codes to represent prolonged services and services with a relatively high degree of complexity. Noting the extensive time and resources that will be needed to adjust to the new coding regime, CMS has delayed the effective date of these rules until 2021. There’s time to prepare for the new E/M coding regime, and it may be altered some between now and 2021, but below is a brief overview of the finalized changes for 2021.

Collapsing Reimbursement for Levels 2-4. Importantly, CMS decided not to change the E/M codes themselves but instead chose to pay the same base reimbursement for E/M code levels 2 through 4.[3] In theory, this will reduce the level of documentation required because physicians will only need to meet the documentation requirements for a level 2 E/M code. However, it will also result in a reduction in reimbursement for many physicians who ordinarily bill higher level E/M codes, unless they also bill for one of the new add-on codes discussed below. Despite the changes in reimbursement levels, physicians do not necessarily have to change how they perform and document E/M services. In fact, CMS expects that physicians will continue to document and bill as they normally would. Noting that other government and private payors (including Medicaid, Blue Cross & Blue Shield, etc.) may continue to use the existing coding structure—or would at least need time to adjust to new coding regimes — CMS decided to retain the existing coding structure, changing the reimbursement only.

Add-On Codes. To account for the reduction in reimbursement associated with the new combined reimbursement rate for E/M levels 2 through 4 and to better align reimbursement with the resources utilized in providing E/M services, CMS decided to add two new add-on codes (again, effective 2021) that can be billed with E/M levels 2 through 4. The first is an add-on code for E/M visits for primary care and certain types of specialized medical care. The second is an add-on code to account for additional resources utilized when physicians have extended visits with patients. Despite the addition of these new codes, CMS indicated that there should not be any additional documentation requirements for E/M services.

Reducing Redundant Data Recording (effective 2019). In response to stakeholder feedback, CMS decided to remove the requirement that physicians document the medical necessity of conducting a visit in the patient’s home instead of in the physician’s office.[4] CMS also decided to streamline documentation requirements by allowing physicians to review information already contained in the medical record (review of systems and past, family and/or social history) and update it as needed, rather than re-recording all of the information.

Proposals Not Adopted. CMS decided not to adopt some of its proposals, including proposals to: (1) reduce reimbursement when E/M services are provided on the same day as a procedure; (2) establish separate podiatric E/M codes; and (3) standardize the amounts of practice expense RVUs for E/M codes.

Conclusion

Overall, there are some changes going into effect in just over a month, and others will likely be reshaped and refined over the next two years before they are implemented in 2021. For now, all physicians need to know is that they can continue to document and bill E/M codes as they always have, but in theory with less redundancy in documentation requirements.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

 

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[3] CMS decided to combine levels 2 through 4 instead of 2 through 5, as originally proposed.

[4] CMS reasoned that this decision is best left to the physician and patient, without applying additional payment rules.

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Medical Association, AMA, Others Take a Stand on New CMS Rule

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Medical Association, AMA, Others Take a Stand on New CMS Rule

The Medical Association joined with the American Medical Association and more than 170 other organizations to support some components of CMS’ “Patients Over Paperwork” initiative, and say three of its components need to be enacted immediately to reduce “note bloat” redundancy, yet also to oppose a proposal to collapse payment rates for physician office visit services over concern about unintended consequences included in the proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program rule.

Read the letter here.

The AMA and other organizations called for the immediate adoption of these proposals:

  • Changing the required documentation of a patient’s history to focus only on the interval since the previous visit.
  • Eliminating requirement for physicians to redocument information that has already been documented in the patient’s record by practice staff or by the patient.
  • Removing the need to justify providing a home visit instead of an office visit.

However, the CMS proposal to “collapse” payment rates for five evaluation and management (E/M) office visit services into two has the potential to create unintended negative consequences for patients.

“We oppose the implementation of this proposal because it could hurt physicians and other health care professionals in specialties that treat the sickest patients, as well as those who provide comprehensive primary care, ultimately jeopardizing patients’ access to care,” the letter states. The AMA and the other organizations joining the letter also oppose a proposed policy that would cut payments for multiple services delivered on the same day.

The organizations note their willingness to work with CMS to resolve issues connected with calculating the appropriate coding, payment and documentation requirements for different levels of E/M services. They also declare their support for the workgroup the AMA created of coding experts who would “arrive at concrete solutions” in time for CMS to implement in the 2020 Medicare physician fee schedule.

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Big Changes Proposed for Evaluation and Management Services

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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

99201 $45 $44
99202 $76 $135
99203 $110 $135
99204 $167 $135
99205 $211 $135

 

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

Code           2018 Payment Rate             CY 2018 New Payment Rate

99211 $22 $24
99212 $45 $93
99213 $74 $93
99214 $109 $93
99215 $148 $93

 

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.

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