Practice Management Alert

A steady flow of small E/M changes are heading your way.

Don’t worry too much about a sudden deluge of changes regarding evaluation and management (E/M) documentation, coding, and payment. The Centers for Medicare and Medicaid Services (CMS) has instead decided to give Medicare providers more time to ramp up and review.

Context: Back in July, CMS dropped some bombshells in its Medicare Physician Fee Schedule (MPFS) CY 2019 proposed rule. The release offered up a virtual manifesto of E/M changes that aimed to reshape the way the bread-and-butter codes will be documented and paid in the future. However, due to overwhelming stakeholder feedback — much of it negative — the agency has resolved to implement the E/M updates over the course of two years, with only a few subtle modifications for CY 2019, according to the MPFS final rule released on Nov. 1 and published on Nov. 23 in the Federal Register.

Resource: Consult the 2,378-page final rule at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

“Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” said CMS Administrator Seema Verma  in a release on the MPFS. “Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors.”

Verma maintained that the policies would decrease provider “burnout” and improve patient care. Plus, “it also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort,” she said of the final rule.

Proposed Rule Commenters Worried About Speed of Changes

Why the turnaround? Despite positive reviews from providers about the paperwork reductions and E/M coding and payment reforms, practices commenting on the rule remained worried about implementing the changes so quickly — to say nothing about the single blended-payment rate change-ups the MPFS proposed. In fact, most were in favor of streamlining documentation requirements that often bump up denials.

The aggressive pace that CMS was pushing to put its plan in place, however, caused some stakeholders to question how they could have their practices and systems up and running for a 2019 rollout.

“Commenters largely objected to our proposal to eliminate payment differences for office/outpatient E/M visit levels 2 through 5 based on the level of visit complexity,” the MPFS noted. The general consensus was that most would see significant pay cuts under the change, and many suggested the agency “implement the proposed documentation reduction without the coding/payment policies, or that these policies could be adopted on separate time frames,” the final rule indicated.

Prepare for These E/M Changes in 2019

In 2019 and continuing into 2020, practices should follow the 1995 or 1997 E/M documentation guidelines when reporting E/M office/outpatient visits they bill to Medicare. However, in the final rule, CMS does updated some policies that went into effect on Jan. 1, so it is important that your staff know what’s new.

Review these revised policies in the MPFS final rule for 2019:

• Update home visit decision-making. Comments poured in from practi­tioners who thought that they should be able to make the decision on whether to treat patients at home or in the office — without excessive documentation to prove the medical necessity for venue. CMS agreed and is nixing the requirement. These services fall under CPT® codes 99341 (Home visit for the evaluation and management of a new patient…) though 99350 (Home visit for the evaluation and management of an established patient…), the MPFS noted.
• Accept staff notes. Instead of re-entering “chief complaint and history” data that “ancillary staff” already updated, physicians can plow ahead with E/M office/outpatient visits for both established and new patients, suggested the MPFS fact sheet.
• Focus on patient changes. Documenting new issues for established patients for office/outpatient visits is vital for quality care, and CMS will now allow providers to focus on that rather than information already in the medical record, especially if there’s evidence the physician reviewed the details, the agency said. “Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so,” the fact sheet says.
• Cut down on duplicates. The agency wants to simplify documen­tation for teaching physicians by removing “potentially duplicative requirements for notations,” particularly if residents or other medical staff have already uploaded their notes, the MPFS indicated.

Even the small rollbacks in 2019 will make a difference for providers struggling with too much administration. “There is little doubt that efforts to reduce regulatory burdens and simplify the documentation requirements for E/M visits will be welcomed by physicians and hospitals,” says attorney Benjamin Fee, Esq., of Dorsey and Whitney LLP in the Des Moines, Iowa, office.

CMS Acknowledges Stakeholders With 2019 Implementations

In the final rule, CMS mentions several comments about stakeholders’ requests that the agency involve the American Medical Association (AMA) — which controls and maintains the CPT® code set — in the E/M policy process. And that should come as no surprise, since the organization has strongly advocated for paperwork cutbacks for clinicians for years. CMS answered the AMA’s call with its streamlined measures for CY 2019 in the MPFS, and the physician organization couldn’t be happier.

“With physicians facing excessive documentation requirements in their practices, it is a relief to see that the Administration not only understands the problem of regulatory burden but is taking concrete steps to address it,” stressed Barbara  L.  McAneny,  MD, AMA president, in a press release on the final rule. “Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records.”

Resource: Find the MPFS CY fact sheet at www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year.