Medicare Compliance & Reimbursement

The 2020 rule aims to fix other E/M issues, too.

Recent evidence suggests that stakeholder feedback really does impact the Medicare proposals. However, as the feds continue to streamline documentation and reverse policies midstream because of the public’s voracious input, it’s open for debate whether all the changes are really helping providers and healthcare.

Context: The Centers for Medicare & Medicaid Services (CMS) reversed course on its 2019 E/M blended payments’ promises in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) proposed rule, published in the Federal Register on August 14. The agency chucked last year’s E/M flat rate proposals and decided to stick with a tiered system after extreme public outcry against the unpopular policy change.

Here’s why: “Physician stakeholders expressed concerns that the blended payment rates” might “inappropriately incentivize multiple, shorter patient visits and lead to practitioners prioritizing treatment of less complex patients,” explain partner attorney Douglas A. Grimm, FACHE and attorney Ashley P. Williams of national law firm Arent Fox LLP, in the Health Care Counsel Blog.

So taking the public’s worries to heart, the agency instead proposes “to align [its] E/M coding with changes laid out by the CPT^® Editorial Panel for office/outpatient E/M visits,” says a CMS fact sheet on the rule. “The CPT^® coding changes retain five levels of coding for established patients, reduce the number of levels to four for office/outpatient E/M visits for new patients, and revise the code definitions.”

Check Out the Details

In addition to nixing the blended E/M payment rate, CMS hopes to implement other E/M changes that will impact code determinations, usage, and more. Here is a quick overview of what the CY 2020 MPFS proposes for E/M services in the future:

• Cut CPT^® 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) and go with four options for new patient E/M visits.
• Stick with the current five levels for E/M services for established patients.
• Let providers use time and medical decision-making to determine the E/M service level.
• Rework E/M code definitions to align with CPT^® Editorial Panel guidance.
• “Adopt [American Medical Association] AMA RUC-recommended values for the office/outpatient E/M visit codes for CY 2021 and the new add-on CPT^® code for prolonged service time,” the fact sheet notes.
• Allow clinicians to decide whether to perform a history or exam if medically appropriate.
• Update with a new add-on code for prolonged services.
• Merge a “Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-pro­cedural specialty care” into one code, CMS suggests.

Industry input: These proposed changes will surely bring glee to many worried providers, but they are not alone. Several medical groups and industry organizations were relieved that CMS walked back some of its more alarming E/M policies.

“We are pleased to see important policy revisions that will bring us closer to a more patient-centered healthcare system that promotes the key principles of affordability, accessibility, quality and innovation,” said AMA President Patrice A. Harris, MD, MA, in a statement on the CY 2020 MPFS.

Harris adds, “The proposed changes to documenting and coding for office visits will streamline reporting requirements, reduce note bloat, improve workflow, and contribute to a better environment for healthcare professionals and their Medicare patients.”

Timeline: If finalized, CMS plans to implement these E/M changes on January 1, 2021.

Stay tuned as Medicare Compliance & Reimbursement continues to break apart and analyze different aspects of the proposed rule in future issues.

Resource: Read the CY 2020 MPFS proposed rule in the Federal Register at  www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other.