Medicare Compliance & Reimbursement

New proposals will hit some specialists hard, CMS statistics suggest.

Due to overwhelming feedback, CMS has proposed not only changing the documentation requirements of evaluation and management (E/M) services, but also creating a single relative value unit for both office and outpatient E/M level 2 through 5 codes. These “historic” updates would greatly impact some physicians’ take home pay — and not for the better.

Details: CMS plans on updating CPT^® codes 99211 through 99215 as well as 99202 through 99205 to reflect what its calling a “blended payment rate,” offering a single relative value unit (RVU) amount for the code sets, according to the proposed Medicare Physician Fee Schedule (MPFS) for 2019 out on July 12. The proposed rule is set for publication in the Federal Register on July 27.

Tables’ 19 and 20 of the MPFS maintain that providers billing codes 99211-99215 would receive $93 for each code and $135 for 99202-99205. This will be a massive change from current standards, as the higher-level codes like 99215 and 99205 — which are the bread and butter of many Medicare practices’ reimbursement — pay $148 and $210 respectively.

Feds input: “Due to the magnitude of the proposed coding and payment changes for E/M visits, it is unclear how the distribution of specialties across E/M services would change,” cautions the MPFS proposed rule.

At this point however, the agency maintains that it can’t be certain how specialists will react to the E/M code changes. “We are concerned that such changes could produce anomalous results for indirect [practice expense relative value unit] PE allocations since we do not yet know the extent to which specialties would utilize the proposed simplified E/M codes and proposed G- codes,” the MPFS says.

Though CMS does estimate that some clinicians will experience a windfall while others have much to lose if the changes are implemented. Overall, specialists who bill a substantial amount of higher level E/M codes may see pay cuts with the single RVU system, suggests the MPFS.

Take a look at these CMS estimates of who may benefit and who may suffer should the E/M blended payment rates be instituted:

Top 5 Winners with Proposed Unadjusted E/M Single RVU Amounts

*Data from Table 21: Unadjusted Estimated Specialty Impacts of Proposed Single RVU Amounts for Office/Outpatient E/M 2 through 5 Levels

Top 5 Losers with Proposed Unadjusted E/M Single RVU Amounts

*Data from Table 21: Unadjusted Estimated Specialty Impacts of Proposed Single RVU Amounts for Office/Outpatient E/M 2 through 5 Levels

Good news: Though some of these statistics are shocking, they reflect only the baseline payments. “Table 21 characterizes the estimated overall impact for certain physician specialties, of establishing single payment rates for the new and established patient E/M code levels 2 through 5, without any of the additional coding or proposed payment adjustments,” advises the MPFS.

In actuality, when multiple procedure payment reductions (MPPRs) are calculated on the E/M services combined with G-code add-ons and technical adjustments, the output shifts and specialty percentages change, indicates the proposed rule. With the alterations figured into the E/M payment equation, ob-gyns and nurse practitioners have the most to gain, according to the MPFS Table 22 guidance.

“Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy,” maintains Seema Verma, CMS Administrator in a “Letter to Doctors” on July 16. “We believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden.”

Reference: You can read more about the possible E/M changes at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf.