Get to know how these new CMS proposed rules might affect your practice. Fee schedule changes to most evaluation and management (E/M) services have been relatively safe from CMS intervention over the past few years. As for 2019, however, it’s looking like otolaryngology practices, among other specialties, may have to prepare for some crucial CMS revisions to how they bill, document, and pay for E/M services— which could have a profound impact on your practice’s bottom line. Take a look at these new incoming policies and changes to the E/M reimbursement structure to understand how your practice may be positively — or negatively — affected. Understand How Proposal Affects E/M Payment Rates Background: CMS released its proposed Medicare Physician Fee Schedule (MPFS) for 2019 on July 12, and it includes what the agency is calling “historic” E/M documentation changes to the outpatient office visit codes (99201-99215). Those changes include the following: If this sounds so appealing that you’re wondering if there’s a “catch,” note that there is. CMS is proposing “new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services,” the agency said in a Fact Sheet about the change. The payment levels are proposed as follows: This would mean that payments for level five codes would go down, while pay for level two codes would go up. Practices that report a lot of level five codes (ie, practices who care for more complex patients that others) would be likely to lose money, but some practices would see gains, says Cyndee Weston, CPC, CMC, CMRS, executive director of the American Medical Billing Association (AMBA) in Davis, Oklahoma. Check Out These 3 ENT Examples of How Pay Could Change To determine the impact that this change might have on otolaryngology care practices, Otolaryngology Coding Alert reviewed the utilization data for three different otolaryngology care practices and calculated how it would impact each of them. These calculations assume that the otolaryngologists will earn $93 for each of the following codes under the proposal, and that they currently bring in the following average reimbursement for 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making …) -99215 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity …) based on the 2018 fee schedule: Impact to Practice 1: Otolaryngologist in South Florida: Total difference: This practice earned $61,669 for these four codes under today’s payment structure, and would earn $52,452 under the proposal. This practice would see $9,217 less pay under the proposal for these four codes. Impact to Practice 2: Otolaryngologist in Western Kentucky: Total difference: This practice earned $56,825 for these four codes under today’s payment structure, and would earn $61,194 under the proposal. This practice would see $4,369 more pay under the proposal for these four codes. Impact to Practice 3: Otolaryngologist in Northwestern California: Total difference: This practice earned $315,529 for these four codes under today’s payment structure, and would earn $222,456 under the proposal. This practice would see $93,073 less pay under the proposal for these four codes. Bottom line: One of the three practices would come out better under the proposal than it does now, but the two practices with higher utilization of levels four and five would lose money under the proposed changes. Of course, this doesn’t mean your otolaryngologist will necessarily model the same results as these practices. If you know how frequently you reported each of these codes, you can perform a similar calculation to determine how the change would affect you. Would Documentation Guidelines Hurt You? Keep in mind that if the proposal is finalized, you would have to be ready to code your charts based on new criteria. For instance, if the code level ends up being based on medical decision making (MDM) rather than the current method of history, MDM, and exam, there could be a learning curve for some practices, says Michael Granovsky, MD, FACEP, CPC, president of LogixHealth, a national coding and billing company based in Bedford, Massachusetts. “MDM can be subjective – the risk table is not black and white unless you’re using the intervention column, which is probably historically the least relevant.” Certainly, the inclusion of a suggested E/M change in the fee schedule proposal doesn’t mean that a change will actually happen. Keep an eye on Otolaryngology Coding Alert for all the latest on whether CMS moves toward finalizing these proposals. Resource: For a closer look at the MPFS proposed rule for CY 2019, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf.