# CMS E/M Services Documentation Guidelines and Burden Reduction Listening Session



## Pathos (Jun 26, 2018)

So this post is more of a discussion post, rather than posing a question. However, in case you missed it, CMS held a special E/M listening session where stakeholders and other folks from the community were invited to call in and comment on a number of questions. The intention was to learn from stakeholders and the community which direction they would like the E/M guidelines to change. CMS does acknowledge that the current 1995/1997 E/M guidelines are cumbersome and would like to update them, hence the Listening session held March 21st of this year. CMS did also mention that this process might be multi-year, however some people are hopeful that some updates might even start next year (2019).

Since I deal with E/M audits on a daily basis, I am seriously excited about this upcoming change. I wholeheartedly agree that the current E/M guidelines are in a need of an overhaul. I am very interested to see which direction CMS will end up taking with the comments during the Listening session. The reason for this post is not just to notify the AAPC forum, but also to pick other coders' brain on this upcoming change.

Here is the transcript link from the session:

E/M Services: Documentation Guidelines and Burden Reduction Listening Session


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## Pathos (Jul 16, 2018)

*Update*

My MAC (Noridian) published this MLN Connects Special Edition which includes several proposed changes to the Medicare PFS and QPP. This includes updating the E/M guidelines:

*Streamlining E&M Payment and Reducing Clinician Burden:*

CMS and the Office of the National Coordinator for Health Information Technology have heard from stakeholders that CMS's extensive documentation requirements for E&M codes have resulted in unintended consequences. To meet these documentation requirements, providers have to create medical records that are a collection of predefined templates and boilerplate text for billing purposes, in many cases reflecting very little about the patients' actual medical care or story.

Responding to stakeholder concerns, several provisions in the proposed CY 2019 PFS would help to free EHRs to be powerful tools that would actually support efficient care while giving physicians more time to spend with their patients, especially those with complex needs, rather than on paperwork. Specifically, this proposal would:
• Simplify, streamline and offer flexibility in documentation requirements for E&M office visits — which make up about 20 percent of allowed charges under the PFS and consume much of clinicians' time
• Reduce unnecessary physician supervision of radiologist assistants for diagnostic tests
• Remove burdensome and overly complex functional status reporting requirements for outpatient therapy


Here's the actual proposed Federal Rule (will be published on 7/27/18)

CMS Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
Proposed Rule for the Quality Payment Program Year 3 Fact Sheet
The Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration


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## TTcpc (Jul 16, 2018)

Thank you for sharing this information.  It will be interesting to see what happens with E/M documentation over the next several years.  I am currently in the middle of my providers who spend a large amount of time in counseling and coordination of care (peds multi-specialty group) and the coding team who is on them about not meeting the History/Exam/MDM elements.  It gets very frustrating as an educator teaching something that everyone that looks at it can interpret it so differently and so much "gray" area.


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## Pathos (Jul 17, 2018)

Yes, I am watching this carefully (got several notifications setup to follow any updates from CMS/local MAC, etc.) since it's a hot-button subject right now.

In regards to the "gray areas" of E/M, I would recommend you get your upper medical administration involved. When CMS is not providing clear-cut guidelines for any parts of the E/M process, we have counseled with our Chief Medical Officer and upper management to make certain rulings, based on *current *rules and guidelines. This way everyone is on the same page and hopefully have your back covered when educating both providers and office staff.

CMS released a short introductory YouTube video about their "Patients over Paperwork" initiative, which is this focus on reducing the burden E/M is currently causing.


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## Pathos (Jul 26, 2018)

*Another Update*

CMS has released another clip on the upcoming propsed changes for 2019 E/M guidelines.

In brief, the main changes are:

One single payment rate for all outpatient E/M visits.
Document requirements are associated with E/M level 2.
If PFSH has already been documented in a previous note, unless there is a pertinent update, then there is no need to redocument.
Focus is on providers spending less time documenting, and more time doing patient care.
CMS recognizes lower reimbursement on the higher E/M levels (4-5), however this should be offset by increased productivity due to significant reduced documentation time.
Focus will be on MDM (did not specify much further).

Here's the link.


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## Pathos (Jul 30, 2018)

Here is another CMS PDF slideshow regarding more tangible changes, including Physician Fee Schedule.

*NOTE*: This is *STILL* a proposal, and not actually set in stone, yet. However, knowing CMS history on proposed rules, they will likely make few changes and move forward with most of the proposal.


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## Pathos (Aug 14, 2018)

Found an interesting news article from CMS' Newsroom, which explains each Proposed rule, including:


To allow practitioners to choose to document office/outpatient E/M visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or alternatively practitioners could continue using the current framework;
To expand current options by allowing practitioners to use *time* as the governing factor in selecting visit level and documenting the E/M visit, *regardless* of whether counseling or care coordination dominate the visit;
To expand current options regarding the documentation of history and exam, to allow practitioners to focus their documentation on *what has changed* since the last visit or on pertinent items that have *not changed*, rather than re-documenting information, provided they review and update the previous information; 
To allow practitioners to simply *review and verify *certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it; and
To recognize efficiencies that are realized when E/M visits are furnished in conjunction with other procedures, we propose a multiple procedure payment adjustment that would apply in those circumstances.  We also propose new coding to recognize *podiatry E/M* visits that would more specifically identify and value these services.  We propose a *new prolonged face-to-face E/M code*, as well as a technical modification to the practice expense methodology.


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## Pathos (Sep 11, 2018)

CMS has another Listening Session where the Proposed Rules were brought up again, and discussed in detail. 

Session held on August 22, 2018 1:30 pm ET.

There were three parts to this Session:

1) Documentation Requirements and Payment for Evaluation and Management (E/M) Visits
2) Advancing Virtual Care
3) Quality Payment Program

Since this thread is mainly about E/M, I will focus on the first one.

As mentioned above, the *PROPOSAL* is to simplify the requirements for E/M billing by only allowing four payment rates (two Established and two New Patient rates):

New Proposed Rates for Established Patient visits:
99211:    $24
99212-5: $93

New Proposed Rates for New Patient visits:
99201:    $44
99202-5: $135

The Proposal also included Add-on codes (HCPCS G-codes), to factor additional complexity for primary care (*GPC1X*) and specialty care (*GCG0X*). The suggested specialty care were presented:  Endocrinology, Rheumatology, Hematology/oncology, Urology, Neurology, Obstetrics/gynecology, Allergy/immunology, Otolaryngology, Cardiology, or Interventional pain management-centered care (note that the QA comments revealed that this list is not exhaustive, so some leeway might be available). Additionally, a 30 minute prolonged care code was also proposed.

Here is a quick rundown on the Proposed Add-on codes:
~$*5* add-on payment to recognize additional resources to address inherent complexity in E/M visits associated with *primary care services*.
~$*14* add-on payment to recognize additional resources to address inherent visit complexity in E/M visits associated with certain *non-procedural based care*.
A multiple procedure payment adjustment that would *reduce *the payment when an E/M visit is furnished in combination with a *procedure *on the *same **day*.
~*$67* add-on payment for a 30 minute *prolonged *E/M visit

The following QA session for the *Proposed *E/M changes were quite interesting and I recommend reviewing those as well.

The Advancing Virtual Care is a step towards broadening telehealth to patients and giving them more options. Recommended read.

If you are involved with Quality Payment Program at your facility, then this section is another must-read as well.

CMS is still asking for public comments, so you still have an opportunity to submit your thoughts and comments.

CMS Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session

Remember, these are still *PROPOSED* rules and not yet set in stone, but I do not expect large fluctuations from what has been presented.


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## Pathos (Oct 2, 2018)

*AAPC Knowledge Center article*

AAPC published an article on the proposed rule changes:

AAPC Knowledge Center


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## jhendrix08 (Oct 5, 2018)

Wow...great resources here. Thanks for taking the time to keep this thread updated!

I see that no one has commented so far...or asked any questions.  Hope it's ok that I ask one! 

I'm not entirely clear on the reduction of payment discussion:

"An E/M multiple procedure payment adjustment to account for duplicative resource costs when E/M visits and procedures with global periods are furnished together.

Essentially, this means CMS would reduce payment by 50 percent for E/M services that are submitted with modifier 25 Significant, separately identifiable Evaluation and Management (E/M) by the same physician or other qualified health care professional on the same day of the procedure or other service on the same day as a zero global day procedure."

So...if a patient is seen by the physician and also receives say, a knee injection, testosterone injection, EKG, or vaccine at this appt, this would mean that we would receive a payment reduction of 50% for the procedure? So the E/M code would be paid at it's full reimbursement but the vaccine or EKG would be reduced.

Do I have that right???? 

How could that payment reduction be avoided? Having the patient come BACK in for the vaccines/injection? Yikes. That isn't very fair to the patient and won't fly in our office. 

I really appreciate any feedback!!


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## cgaston (Oct 5, 2018)

jhendrix08 said:


> Wow...great resources here. Thanks for taking the time to keep this thread updated!
> 
> I see that no one has commented so far...or asked any questions.  Hope it's ok that I ask one!
> 
> ...





I interpreted it to mean the E&M would be reduced by 50%


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## Pathos (Oct 8, 2018)

jhendrix08 said:


> Wow...great resources here. Thanks for taking the time to keep this thread updated!
> 
> I see that no one has commented so far...or asked any questions.  Hope it's ok that I ask one!
> 
> ...





Thanks for the good feedback jhendrix!

According the the CMS Transcript of the 8/22 Listening Session on page 11:

_"*Shan McDaniel*: 
Hi. I’m Shan McDaniel with Medron/MedData Service Billing. My question is a little bit related to the place of service issue, meaning are we going to receive a reduction if the place of service, even if it’s one of the 10 codes in question, not like the ER visit earlier but just simply at an outpatient setting or a different setting than that of your office, is the site of service differential coming into play?
And the second question is if you are imposing the multiple procedure payment adjustment, if there are more than one procedure that – procedures that have the multiple indicator two, as I appreciate, those all will be reduced in half or just the lowest one will be reduced in half related to the 25-modifier usage?

*Nicole Cooney (CMS)*: Give us one second.

*Emily Yoder (CMS)*: Thank you for waiting. So, in terms of your first question, the site of service differential will continue to apply for these codes. And, then, for your question about the MPPR, under the MPPR,* the first procedure is paid at – or the most expensive procedure is paid at 100 percent. And, then, the less expensive procedures are paid at 50 percent*."_

They do continue:

_*Shan McDaniel*: All of the less expensive that have indicator – multiple indicator two, what I thought I heard you say, are subject to 50-percent reduction?

*Emily Yoder (CMS)*: That is correct.

*Shan McDaniel*: *That’s a little bit extreme*. Going back to the site of service, can you ask that they indicate what the rates for the new E/M primary care and complexity and each one of the add-ons in addition to the new flat fees or the blended fees – what those are rather than – I guess I’m presuming that what you posted is the office place of service. Right? Can you ask that they share with us what’s the site of service rate will be in all of the scenarios?

*Emily Yoder (CMS)*: Yes, we can – we can do that.

*Shan McDaniel*: Is it typically in your mind just to present right now or – that’s not what I’ve experienced, but maybe.

*Lindsey Baldwin (CMS)*: Yes. So, these services are priced in both the facility and the non-facility setting. And the public use files that are posted along with the rule – they provide the RVUs for both settings." 

...

*Shan McDaniel*: And do you reduce the RVUs of the multiple add-on procedures when you knock them down by 50 percent or we still get the RVUs? How does that …

*Lindsey Baldwin*: The MPPR would apply to the total payment.

*Shan McDaniel*: Total payment and the RVU (inaudible)."_


Note that the rule is *not yet* finalized, however knowing CMS history I doubt they will deviate greatly from what they have proposed. CMS did ask for public comments, however the deadline passed last month. I would expect and prepare for the rules to go live as is, until we hear otherwise from CMS.

However, in short from the research and what I am getting from CMS:

1) The E/M will not get reduced (any further) than the proposed rate (stay at 100%), regardless of additional procedures.
2) If there is another procedure outside the E/M (vaccines, Rx injections, etc.) then the rest will be reduced by 50%. This would either result in overall reduced payment to the provider for doing multiple procedures on the same day (bad day for multi-specialty groups), or have the patient come back for the procedures (bad day for the patient).

Overall, this would probably mean that practice managers will have to figure out another way to offset these reduced payments somehow. Some practices might think about pulling out of Medicare completely, which in return will result in worsening of health care access for seniors and other Medicare beneficiaries. I don't have the perfect answer on this one.

I have read some comments that this is the result of incorrect Modifier 25 billing, but this is not verified by CMS or any other official group.


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## jhendrix08 (Oct 8, 2018)

I can't thank you enough for your reply to my question....you've made it very clear to understand. I'm subscribed to the Medicare updates and have been doing a lot of reading to keep informed...it makes my head spin! 

We are a PCP office and it's common practice for us to do an injection or vaccine on the same day as an E/M service so my provider is not going to be thrilled when I break the news to him about this. We'll definitely have to brainstorm about how to come up with a way to be fair to the practice and be fair to the patient. 

Thanks again!


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## Pathos (Oct 8, 2018)

You bet!

However, it's annoying for everyone involved (provider AND patient), and might mean increased depreciation of the quality of Medicare (less provider incentive to stay with Medicare, as they continue to cut reimbursements). Again, there is still some fine tuning that needs to be done to the proposed rules, so the actual rule might/probably will look different from what we know now. How much of a swing is difficult to answer now. Alternatively, CMS might give everyone extra time to prepare for this radical rule shift.

Time will tell. Feel free to ask any other questions about this proposed rule, and I'll see what I can dig out.


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## jhendrix08 (Oct 9, 2018)

Thanks, Gordon! I'm going to break the news to my provider today...yikes!  I'm running a report now on how many straight Medicare patient's we have...I know that will be his next question.

Enjoy your day!


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## Pathos (Oct 9, 2018)

jhendrix08 said:


> Thanks, Gordon! I'm going to break the news to my provider today...yikes!  I'm running a report now on how many straight Medicare patient's we have...I know that will be his next question.
> 
> Enjoy your day!



You're welcome, and good luck!

PS. My name is not Gordon, I just really like that quote


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## Kristen Bensel (Oct 10, 2018)

I find this proposal interesting for many reasons, but one that comes to mind a lot is how much of this documentation burden is being blamed on the 95/97 guidelines for E/M that is actually related to the added documentation requirements that are for meaningful use and other EHR issues that were mandated by CMS? 

I know that for the clinic I work in, the providers are most burdened by having to use SNOMED terms (which are ridiculous in my opinion) and making sure their meaningful use quotas are met during each visit that they spend more time having to document than patient care.

How will this in adversely affect continuity of care for the patient that is sent out to a specialist, or for a consult if the chart notes are not going to be held to the same standard as with the current guidelines. Are those providers going to be getting enough information in the chart notes they review to get a complete view of the patients medical history? 

I guess I wonder if this proposal is CMS's way for trying to cover themselves as causing some of this issue since EHR's were mandated to be used. A lot of the burden the EHR was supposed to ease for the provider seems to have been the opposite. At least from my experience and view point.

And those are my two cents!


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## jhendrix08 (Oct 10, 2018)

I'm laughing at myself!!! Totally missed the fact that "Gordon" was with the quote. Ha!


And Kristen....agreed!!


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## Pathos (Oct 17, 2018)

Kristen Bensel said:


> I find this proposal interesting for many reasons, but one that comes to mind a lot is how much of this documentation burden is being blamed on the 95/97 guidelines for E/M that is actually related to the added documentation requirements that are for meaningful use and other EHR issues that were mandated by CMS?
> 
> I know that for the clinic I work in, the providers are most burdened by having to use SNOMED terms (which are ridiculous in my opinion) and making sure their meaningful use quotas are met during each visit that they spend more time having to document than patient care.
> 
> ...



I am not entirely sure what effect the Proposal will have on specialists, other than what I have mentioned previously in this thread. I think time will ultimately tell. I am gathering that we shouldn't expect all payers to automatically jump on board with this major change (which is still NOT finalized), however I presume several will eventually.

I do see the logic behind reducing documentation requirements and the inordinate time providers are spending just in order to fulfill some requirement and not necessarily be logical. I also think that this Proposal is a way to mitigate costs and a result of too much upcoding (billing a higher code of what was medically necessary). I just hope that providers (like the Family Medicine Doc I talked to the other day) will still focus on what is ethically reasonable and necessary when it comes to documentation, and not just to hit a certain E/M level.

I just finished listening to one of AAPC's Free Webinars on Industry Trends Panel Discussion (Mike Miscoe being one on the panelists), where the CMS E/M Proposal was discussed. I recommend listening to the webinar, and grab the 1 CEU while you're at it 


And jhendrix, no problem


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## Pathos (Nov 1, 2018)

As foreseen, CMS has officially finalized their rule and have released a news article. Since there are many changes, I will highlight the ones which are pertinent to this thread:

"_For CY *2019* and CY *2020*, CMS will *continue* the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare.

Beginning in CY *2021*, CMS will further reduce burden with the implementation of payment, coding, and other documentation changes. Payment for E/M office/outpatient visits will be simplified and payment would vary primarily based on attributes that do not require separate, complex documentation. Specifically for CY 2021, CMS is finalizing the following policies: 

*Reduction in the payment variation for E/M office/outpatient visit levels by paying *a single rate* for E/M office/outpatient visit *levels 2 through 4 *for established and new patients while maintaining the payment rate for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients._"

There are some Telehealth, PTA/OTA, Radiology Assistant, Ambulance, and many other updates you should read up on. Especially if you have anything to do with your company's Revenue Cycle.

Here is the link:

Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019


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## jhendrix08 (Nov 5, 2018)

I was signing on with the hope that you would have posted updated info and here you are! ;-) I was reading through all of the email articles I received and it's A LOT and a bit confusing. 

So, for the new E/M reimbursement (Patients over Paperwork), it's sounding like this won't become effective until 2021? Do I have that right??

Thanks so much for being so helpful through all of this....much appreciated.


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## Pathos (Nov 5, 2018)

jhendrix08 said:


> I was signing on with the hope that you would have posted updated info and here you are! ;-) I was reading through all of the email articles I received and it's A LOT and a bit confusing.
> 
> So, for the new E/M reimbursement (Patients over Paperwork), it's sounding like this won't become effective until 2021? Do I have that right??
> 
> Thanks so much for being so helpful through all of this....much appreciated.



Yes, CMS released a wealth of information which is more manageable if distilled into smaller portions. However, I was hoping CMS would delay the E/M code bundling a little before pushing forward which is appears they have. While that allows most providers to prepare for the massive change, it is still inevitable much like the ICD-10 change. However, unlike the ICD-10 change, the monetary reimbursement rate will most likely alter the traditional mindset of E/M coding and provider production. I foresee many commercial carriers to eventually follow CMS footsteps, however the time frame for this is still unknown.

So, to answer your question more directly: *YES*, according to the News release from CMS, the E/M code fee bundling (2-5 levels) will not happen until beginning of 2021 (unless they push this date out further).


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## jhendrix08 (Nov 5, 2018)

Thank you! And thanks again for this thread...


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## Pathos (Nov 8, 2018)

jhendrix, you bet!

Also, CMS released a letter to every (apparently) CMS enrolled clinician regarding the major changes.

The content is similar to the News Release posted previously, with the following foci:

"Effective January 1, 2019, we will:
• Simplify the documentation of history and exam for established patients such that
when relevant information is already contained in the medical record, clinicians can
focus their documentation on what has changed since the last visit rather than having
to re-document information.
• Clarify that for both new and established E/M office visits, a Chief Complaint or other
historical information already entered into the record by ancillary staff or by patients
themselves may simply be reviewed and verified rather than re-entered.
• Eliminate the requirement for documenting the medical necessity of furnishing visits in
the patient’s home versus in an office.
• Remove potentially duplicative requirements for certain notations in medical records
that may have previously been documented by residents or other members of the
medical team.

Beginning in 2021, we will implement payment and coding changes to achieve additional
burden reduction. Billing for visits will be simplified and payment will vary primarily based on
attributes that do not require separate, complex documentation. For 2021, we intend to:
• Implement a single payment rate for visits currently reported as levels two, three, and four.
These represent a majority of office/outpatient visits with clinicians. This means that for the
majority of visits, the required documentation related to payment will be limited to what is
required for a level two visit.
• Retain a separate payment rate for the most complex patients – those currently reported
through use of the level five codes. Also we will retain the current separate code for level
one visits, which are predominantly used for visits with clinical support staff.
• Introduce coding that adjusts rates upward to account for additional resource costs
inherent and routine in furnishing certain types of non-procedural care. These codes would
only be reportable with level two through four visits, and their use generally would not
impose new per-visit documentation requirements.
• Introduce coding that adjusts rates upward for use with level two through four visits to
account for the additional resource requirements when practitioners need to spend
extended time with a patient.
• Allow for flexibility in how level two through five visits are documented – specifically
introducing a choice to use the current framework, medical decision-making, or time...

...A two-year delay for the payment and coding changes will give clinicians more
time to integrate changes in workflow that may be required. In addition, the extra time will
allow CMS to continue working with the clinician community on this effort."

Buckle up, because the changes are coming (just like Winter after Fall).


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## jhendrix08 (Nov 12, 2018)

I've registered for a listening session on this topic on 11/19.  I'll be happy to share any new info I take away from that but I have a feeling it will be more of the same of what's already been released. 

Have a great week!!


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## Pathos (Nov 12, 2018)

Anything new to add (with references preferably), is always welcomed.

Who is the vendor/presenter?


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## jhendrix08 (Nov 13, 2018)

CMS is the presenter.

Here's the link to register, I believe it's not full yet. 

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2018-11-19-PFS.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending


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## Pathos (Nov 13, 2018)

Great, I will give that webinar a shot!


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## caroline75771 (Nov 15, 2018)

*CMS E/M Documentation Guidekubes*

Thank you for sharing.
I've also registered.  Hope to discuss and hear feedback after presentation.
Caroline




jhendrix08 said:


> CMS is the presenter.
> 
> Here's the link to register, I believe it's not full yet.
> 
> https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2018-11-19-PFS.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending


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## jhendrix08 (Nov 19, 2018)

You're welcome! 

I was actually disappointed with today's listening session as much of it was the presenters reading from the provided handout without much elaboration.  I didn't take anything new from it. Am I alone in this? 

Have a great week!


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## Pathos (Nov 19, 2018)

CMS did the same thing when they did their Proposed Rules Webinar, so if you listened/read to that one you shouldn't be too surprised.

I liked that they followed an outline, and they allowed for Q&A sessions. To be truthful, I hung up after Verma (CMS Admin) was done speaking. My time today was limited anyways, but I figured I'd catch up reading the transcript later.

AAPC sums up some of the more pertinent 2019 changes on page 19:

http://aapcperfect.s3.amazonaws.com/5548A1AF-4C9F-49A2-BFE0-BFA7D2344700/4e1df391-35da-4306-9803-39db4a405806/0f1325af-e156-42d0-b575-55e90f2adcd6.pdf

I'll post more once I've read the transcript.


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## Pathos (Dec 5, 2018)

Ok, the Session transcript has now been posted and is available on MLN's site here:

Physician Fee Schedule Final Rule: Understanding 3 Key Topics Call

I recommend reading or listening to the whole session: Audio here

A few quick takeaways:

1) A FAQ is supposed to be released which should answer most of the questions asked in the session
2) Telehealth was brought up several times
3) Quality measures were discussed
4) PFS 200 covered professional services were talked about as well (under Quality really)

I enjoyed the session, however I can't wait to get my hands on the FAQ if it truly will be as great as the presenters are hinting at.

More to come still.


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## kmknott (Dec 19, 2018)

*Have the FAQs been released yet?*

Has anyone seen the FAQs that CMS referenced in the call? I've looked and haven't seen them yet.


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## Pathos (Dec 19, 2018)

I did receive an email from the CMS MLN Events Team, which did include a link to a FAQ. However, the FAQ only addressed one E/M question, and two other MIPS and Quality questions. I held back from posting it here, as I was hoping to get more information from CMS.

Regardless, here is the link to the FAQ I received:

*What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019*? Answer


*How does the MIPS payment adjustment apply to clinicians, especially those who may switch practices during the performance year?* 

A. Below are the general rules on how the payment adjustment is applied, which is different than the legacy programs.  

1.	A MIPS eligible clinician (NPI) who bills to the same TIN in the payment year as they did during the performance period will be assessed the payment adjustment under that TIN/NPI combination according to the final score earned from data submitted/collected under that TIN  

2.	A MIPS eligible clinician (NPI) who bills to a (new) TIN in the payment year that they did NOT bill to during the performance period will be assessed the payment adjustment under that (new) TIN/NPI combination based on the most advantageous final score attributed to that NPI under any TIN/NPI combination for the performance period 


*Are there any changes to the data completeness requirements for the MIPS Quality performance category in 2019? *

A. No, the data completeness requirements are the same as in Year 2 (2018) even with the update to the submission terminology. Individual clinicians or groups submitting quality measure data on QCDR measures, MIPS CQMs, and eCQMs must submit data on at least 60% of the clinician or group’s patients that meet the measure’s denominator criteria, regardless of payer. Individual clinicians or groups submitting quality measure data on the Medicare Part B claims measures must submit data on at least 60% of the applicable Medicare Part B patients seen during the performance period.


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## jhendrix08 (Dec 19, 2018)

I received the same email and haven't seen the full list of FAQ's posted as of yet.


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## LKaf7 (Jan 8, 2019)

Did they release the FAQ yet?


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## Pathos (Jan 11, 2019)

Hello,
I have not seen anything else other than the post I made a few posts up. I would assume the FAQ would be public soon though.


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## Deb2009 (Feb 16, 2019)

Is this official for the ancillary staff to document history?  I am looking for the final rule on this.  Thank you





Pathos said:


> I did receive an email from the CMS MLN Events Team, which did include a link to a FAQ. However, the FAQ only addressed one E/M question, and two other MIPS and Quality questions. I held back from posting it here, as I was hoping to get more information from CMS.
> 
> Regardless, here is the link to the FAQ I received:
> 
> ...


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## Pathos (Feb 18, 2019)

Good morning Deb,

Per CMS:

_"For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. For *CY 2019 and beyond*, CMS is *finalizing *the following policies:

Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.  Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by *ancillary staff or the beneficiary*. The practitioner *may* simply indicate in the medical record that he or she reviewed and verified this information; and
Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians. "_

The guidelines now states that the provider doesn't even have to indicate that he/she reviewed and verified ("may"), so there's that. However, ancillary staff or even the beneficiary can be entered by staff or even the patient. This is a far cry from the much stricter guidelines we used to follow.

Hope that clarifies.


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## Pathos (Feb 21, 2019)

Here is a recap of some of the E/M changes for 2019 in the form of a short (~9 mins) podcast:

https://www.cms.gov/podcast/episode-1-evaluation-and-management-coding


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## Pathos (Apr 1, 2019)

Bumping this back up to the front, since several people are asking for the new E/M changes. Feel free to add (after reading through the whole thing), if you found additional useful material and/or any questions about these new changes.

Thanks!


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