United States: Medicare's Proposal To Streamline Evaluation And Management Documentation And Payment—What Practitioners Need To Know

Last Updated: July 27 2018
Article by Scott Memmott and Kathleen P. Rubinstein

Responding to input from stakeholders who have long maintained that evaluation and management documentation guidelines are too complex and fail to meaningfully distinguish differences among code levels, a proposal by the Centers for Medicare & Medicaid Services would reduce the administrative burden on practitioners but also create winners and losers among medical specialties. While the intention is to give practitioners more time to focus on patient care, some specialties may see decreased payments for same-day visits and procedures across group practices.

The Centers for Medicare & Medicaid Services (CMS) proposed rule for the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies for calendar year (CY) 2019 (Rule) proposes major changes to documentation requirements and payments for office/outpatient visit evaluation and management (E/M) codes (CPT codes 99201 through 99215). These changes purport to give practitioners choices with respect to the appropriate basis for distinguishing among E/M visit levels, decreasing documentation requirements, and reducing variation among E/M visit levels.

CMS's goal in making the changes is to reduce the administrative burden on practitioners so that they can exercise greater clinical judgment and discretion in what they document, focus on what is clinically relevant and medically necessary for the patient, and spend more time on patient care.

CMS notes that although office/outpatient E/M visits compose approximately 20% of allowed charges for PFS services, they haven't been revalued recently to account for significant changes in the disease burden of the Medicare patient population and changes in healthcare practice. In addition, CMS says it is responding to input from stakeholders who have long maintained that the E/M documentation guidelines are administratively burdensome, too complex, and ambiguous; fail to meaningfully distinguish differences among code levels; and are not up to date for changes in technology.

Reduced Documentation Requirements for Office/Outpatient Visit E/M Codes

In a significant change with respect to documentation for office, other outpatient, and home E/M visits, CMS is proposing to allow practitioners to choose, as an alternative to the current framework specified under the 1995 or 1997 coding guidelines, either Medical Decision Making (MDM) or time as a basis to determine the appropriate level of E/M visit.

1995 or 1997 Coding Guidelines

Practitioners would have the option of continuing to use the existing coding guidelines, but the proposed Rule would minimize documentation by only requiring practitioners to meet the documentation requirements for history, physical exam, and MDM that currently are associated with a level 2 office/outpatient E/M visit (except when using time to document the service, as below) and to document the medical necessity of the visit.

CMS acknowledges that practitioners could choose to no longer document many aspects of an E/M visit that they currently document under the 1995 or 1997 guidelines for history, physical exam, and MDM, but that practitioners could choose to document more information for clinical, legal, operational, or other purposes that are consistent with the level of care furnished.

MDM

Practitioners also would have the choice under the proposed Rule of using just MDM to establish the level of an E/M visit. Under this proposal, Medicare only would require documentation associated with a current level 2 CPT visit code and that needed to support the medical necessity of the visit. The proposed Rule allows practitioners to rely on MDM in its current form to document their visits, but CMS is soliciting public comment on whether and how guidelines for MDM might be changed in later years.

Time

As a third option, practitioners could use time as an indicator of the complexity of a visit and as the single factor in selecting the E/M visit level and documenting the visit. The proposal would require the practitioner to document the medical necessity of the visit and show the total amount of face-to-face time spent with the patient.

Although CMS is soliciting public comment on what that total time should be for payment of the new single rate for E/M visits levels 2 through 5, it has included three possibilities in the proposed Rule, namely

  1. using the typical times for E/M visits in the physician time files used to set PFS rates, where recommended by the American Medical Association to the Specialty Society Relative Value Scale Update Committee and then reviewed by CMS as part of its regular rate-setting process;
  2. applying to the typical times the CPT codebook provision that, for timed services, a unit of time is attained when the midpoint is passed; and
  3. requiring documentation that the typical time for the CPT code that is reported was spent face to face by the billing practitioner with the patient.

Under this approach, the total amount of time spent by the billing practitioner face to face with the patient would inform the level of the E/M visit.

Additional Reduced Documentation Requirements Specifically for Home Visits and Same-Day Visits

Medicare beneficiaries don't have to be confined to the home to be eligible for home visits as long as the medical record includes documentation of the medical necessity of a home visit as opposed to an office or outpatient visit. In response to stakeholder input that whether a visit occurs in the home or the office is best determined by the practitioner and the beneficiary, CMS proposes to reduce documentation requirements for home visits by eliminating the Medicare Claims Processing Manual provision that imposes this requirement.

CMS also proposes to eliminate the Medicare Claims Processing Manual's prohibition on billing same-day visits by practitioners of the same group practice and specialty unless there is documentation that the visits were for unrelated problems. Although this policy is designed to address the concern that multiple visits on the same day as another E/M service might not be medically necessary, CMS apparently found persuasive the criticism by stakeholders that this prohibition no longer makes sense because in the current practice of medicine, a practitioner may have areas of medical expertise that are not reflected in the specialty used for Medicare enrollment. For example, a patient may see more than one geriatrician in the same group practice on the same day, but the practitioners have different specialty affiliations. In a situation such as this under the current policy, stakeholders have posited that practitioners often schedule E/M visits on two separate days so that they can get full reimbursement for both visits, thereby unnecessarily inconveniencing the patient.

Removing Redundancy in E/M Visit Documentation

In addition to choosing to use the current documentation framework, MDM, or time to determine the level of E/M visit, the practitioner also has the option of applying proposed policies regarding redundancy and who is required to document information in the medical record.

In response to stakeholders who have expressed that CMS should not require documentation of

information in the billing practitioner's note that is already present in the medical record,

particularly with regard to history and exam, CMS proposes to simplify the documentation of history and exam for established patients and only require practitioners to document what has changed since the last visit or pertinent items that have not changed, "rather than re-documenting a defined list of required elements such as review of a specified number of systems."

CMS expects nevertheless that practitioners still would conduct the clinically relevant and medically necessary elements of history and physical exam, but they would not need to re-record these elements if there were evidence that the practitioner reviewed and updated the previous information. CMS is seeking comment on whether there may be ways to implement a similar provision for MDM or for new patients, not just established patients.

CMS also is proposing to eliminate the requirement for both new and established patients that practitioners reenter information in the medical record regarding the chief complaint

and history that already have been entered by ancillary staff or the beneficiary. The practitioner only need to indicate in the medical record that the information has been reviewed and verified.

Simplifying Payment Amounts by Applying a Single Rate for E/M Levels 2–5

CMS reports in the proposed Rule that, according to input received from stakeholders, the burdens of documenting E/M visits originate not only from the current documentation guidelines, but also from the coding structure itself. Not wanting to create chaos given the wide and longstanding use of these visit codes by both Medicare and private payers, Medicare chose not to propose new coding and opted to stay with the current code set. Rather, the proposed Rule attempts to simplify payment amounts and minimize documentation requirements by reimbursing a single rate for level 2–5 E/M visits for new patients and a different single rate for established patients. These new single payment rates would apply no matter the option chosen by the practitioner to document the visit.

Practitioners still would bill the CPT code for whichever level of E/M service they furnished. CMS believes that by eliminating the distinction in payment among levels 2–5, the need to audit against the visit levels will be eliminated, which will further lessen the burden of documentation.

In order to set relative value units (RVUs) for the single payment rates, CMS proposes to use the five most recent years of Medicare claims data (CY 2012 through CY 2017) to develop resource inputs based on the current inputs for the individual E/M codes, generally weighted by the frequency at which they are currently billed.

Adjusting Single Payment Rates for Resource Costs Associated with Different Types of E/M Visits

After proposing single payment rates for level 2–5 office/outpatient E/M visits that are supposed to appropriately value a typical E/M service, the proposed Rule also plans to create new add-on codes to better capture the differential resources involved in furnishing certain types of E/M visits. The three specific types of E/M visits identified by CMS that differ from the typical E/M visit and have different resource costs are the following:

  • Separately identifiable E/M visits furnished in conjunction with a zero-day global procedure
  • Primary care E/M visits for continuous patient care
  • Certain types of specialist E/M visits, including those with inherent visit complexity

As detailed below, CMS proposes to address this issue with the following policies and rate-setting adjustments to the base single payment rates for new and established patients:

  • A multiple procedure payment adjustment to account for duplicative resource costs when E/M visits and procedures with global periods are furnished together
  • HCPCS add-on G-codes to account for additional relative resources for primary care visits
  • HCPCS G-codes to describe podiatric E/M visits
  • An additional prolonged face-to-face services add-on G-code
  • A technical modification to the practice expense (PE) methodology to address indirect PE associated with E/M visits

Resource Overlap Between Standalone Visits and Global Periods

CMS notes that in cases where a physician furnishes an E/M visit to a beneficiary on the same day as a procedure and gets paid for both because it has been documented that the visit is separately identifiable from the procedure, there are certain duplicative resource costs that are not accounted for in the current E/M code set and associated payment rates, which warrants a payment adjustment. As a result, the proposed Rule reduces by 50% the payment for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit.

HCPCS Add-on G-Code for Primary Care E/M Visits

The proposed Rule asserts that, based on feedback received from practitioners who furnish primary care, primary care E/M visits have greater complexity than other types of E/M visits and have distinct resource costs as a result of the additional time necessary to consider and review the patient's medical needs, coordinate patient care and collaborate with other practitioners, and communicate with and educate patients. CMS notes that because there currently are codes that address non-face-to-face work, such as chronic care management (CCM) and behavioral health integration (BHI), the proposed Rule only addresses the face-to-face portion of a primary care E/M visit service by creating a HCPCS add-on G-code—GPC1X—to be billed with the appropriate level 2–5 E/M code to adjust payment for additional resource costs.

The new primary care G-code only would be used with a standalone E/M visit (as opposed to a separately identifiable visit furnished within the global period of a procedure) with an established patient. CMS anticipates that the new primary care G-code will be billed with

every such visit and that it also may be billed with the proposed new code for prolonged

E/M services described below.

HCPCS Add-on G-Code for E/M Visits with Specialists

The proposed Rule also creates a new HCPCS add-on G-code—GCG0X—to be billed with the appropriate level 2–5 E/M code to adjust payment for the additional resource costs associated with specialty practitioners, specifically E/M visits associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, and interventional pain management.

According to CMS, these specialties apply nonprocedural approaches to "complex conditions that are intrinsically diffuse to multi-organ or neurologic diseases" and that warrant an adjustment for additional resource costs noting that their visits predominantly are reported using E/M visit codes rather than procedural codes. As with the proposed new primary care G-code, this new add-on G-code for specialists only could be used with a standalone E/M visit.

New HCPCS G-Codes for Podiatric E/M Visits

The proposed Rule also creates separate coding for podiatry visits rather than continuing to report them as E/M office/outpatient visits. Using the same options for documentation described above, podiatrists would report visits under new G-codes—GPD0X for new patients and GPD1X for established patients—that more accurately reflect the resource costs of podiatric visits. CMS chose to use this option rather than propose a negative add-on adjustment to the proposed new single payment rates for level 2–5 E/M visits.

Adjustments to PE/HR Calculation

Because indirect costs for each code generally are allocated on the basis of the direct costs specifically associated with a code, and the greater of either the clinical labor costs or the work RVUs, CMS recognized that establishing single payment rates for new and established patient level 2–5 E/M visits could have unintended consequences on certain specialties because the single payment rates no longer will reflect the indirect PE costs previously allocated across the different E/M visit codes.

CMS's proposed solution is to create a single practice expense per hour (PE/HR) value for all E/M visits, including the proposed new HCPCS G-codes, based on the average of the PE/HR across all specialties that bill these E/M codes, weighted by the volume of those specialties' allowed E/M services. CMS believes this more accurately will reflect the mix of specialties billing both the E/M code set and the add-on codes.

New Additional HCPCS G-Code for Prolonged Services

CMS posits in the proposed Rule that now that practitioners have the option of using time to document the appropriate level of E/M visit, there are not adequate existing codes to capture the time of additional services beyond the typical service time. Although CPT codes 99354 (first hour of prolonged E/M beyond the typical service time) and 99355 (each additional 30 minutes of prolonged E/M beyond the typical service time) describe additional time spent face to face with a patient, stakeholders have informed CMS that the "first hour" time threshold is difficult to meet and is an impediment to billing these codes.

In response, CMS is proposing to create a new HCPCS code—GPRO1—for prolonged E/M visit services beyond the typical service time with an initial 30-minute threshold. Because the new prolonged services G-code requires half the time assigned to CPT code 99354, CMS is proposing a work RVU that is half the work RVU of code 99354.

Finally, when a practitioner chooses to document an office/outpatient E/M visit using time and also reports the prolonged services G-code, CMS will require the practitioner to document the typical time required for the initial E/M visit code exceeded by the amount required to report prolonged services.

Predicted Impact of the Proposed Rule

Specialty Specific Impacts

CMS notes that prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to a lack of stakeholder consensus, particularly among specialties. We suspect that will continue to be the case with respect to the proposed Rule. CMS predicts that specialties that bill a large portion of E/M visits on the same day as procedures would experience a decrease in payments. In addition, specialties such as allergy/immunology and cardiology are likely to be negatively impacted by the proposed single payment rates themselves, although not to the same degree as they would have been without the new add-on G-codes. The specialties that CMS predicts will see an increase in payments due to a combination of the new single payment rates and the add-on G-codes include psychiatry and endocrinology.

General Impact

CMS predicts that the documentation changes for office/outpatient E/M visits and the implementation of single payment rates may reduce the documentation time by one quarter of the current time for the average office/outpatient visit. If that is the case, the proposals would save clinicians approximately 1.6 minutes of time per office/outpatient E/M visit, which for a full-time practitioner with a payer mix that is 40% Medicare (60% other payers), the practitioner would have approximately 51 additional hours to spend with patients every year.

The proposed Rule's policy changes would apply to Part B services beginning January 1, 2019. Comments are due September 10, 2018.

This article is provided as a general informational service and it should not be construed as imparting legal advice on any specific matter.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Similar Articles
Relevancy Powered by MondaqAI
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions