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Providers Need to Know About Proposed E&M Codes Changes in 2019

November 15, 2018

E&M Codes Change

In July 2018, the CMS announced its proposed changes to the Medicare Physician Fee Schedule for 2019. Included with the other updates are major changes to the use of certain codes for evaluation and management (E/M) levels 99201 – 99215. After following Medicare contractors for the past several years, as well as receiving feedback of physician concerns about streamlining outdated E/M documentation guidelines, CMS decided to make changes in five main areas:

Reducing unnecessary reporting requirements

Under the proposed changes, Medicare would no longer require providers to document information about history of the current illness and chief complaint if this was previously noted by the practice’s ancillary staff. The intent behind this is to reduce not only wasted time and effort but to better avoid duplication of notation that could impact payments.

New time option for reporting

Physicians will have additional options, starting on January 1, 2019, when choosing service levels or other types of outpatient services. These would include the level of service based on time or through medical decision-making alone, regardless of history level or whether a physical exam is performed.

Under current guidelines, visits based on time require face-to-face time documentation as well as at least 50 percent of the visit spent counseling or in care coordination. This second requirement would be eliminated, with code selection based on length of visit, regardless of amount of time spent counseling.

Medical decision-making as the driving force

Doctors have long complained about increased documentation that contributes nothing to quality of care. Medicare would address that by letting them select their service levels for office visits for both new and established patients, using only the components that concern medical decision-making.

Primary care bump in payment

For visits focused on primary care, providers can receive a small bump in payment by reporting new add-on code GPC1X, with proposed work RVUs 0.07 and estimated $5 value per visit.

A shift to a single rate of payment for coding levels 2 through 5

Under the new rule as originally proposed, level 2 through level 5 both new and established patient office visits would be paid at a single rate, regardless of the reported code.

New patients coded 992002 through 99205 would be paid at about midway between a 99203 and 99204, assigning 1.9 work RVUs to new patient codes. 2018 rates are coded at 99203 at 1.42 work RVUs and 99204 at 2.43 work RVUs, with a midpoint at 1.925.

Established patients coded at 99212 – 99215 would be paid under the proposed rule at just below the midpoint between 99213 and 99214. These would be assigned 1.22 work RVUs to the established patient visit codes. Compare these to the current 2018 rates for 99213 at 0.97 work RVUs and 99214 at 1.5 work RVUs and with a midpoint of 1.235.

These are the aspects of the rule changes that generated controversy since the changes were announced, drawing angry responses from over 15,000 providers, particularly those grouping under the umbrella of the American Medical Association. We’ll examine the reasons for those objections further below.

Physician objections to the proposed level rate changes

Providers must often use a “specific pre-formed phrase” recognizable by the computer’s EHR program to satisfy the requirement of performing a patient’s annual exam. One recommendation from some physicians for CMS would be to build in incentives to keep and document the most important factors of a patient’s medical history while blending with the non-paperwork/ documentation elements of the work that is being performed.

While most physicians agree that reducing the complexity and volume of time-consuming reporting is a good thing, the proposal to flatten E/M codes wasn’t a change they had asked for nor expected.

Many providers worry that CMS’s attempts to decrease documentation, even when it involves more complex care for sicker patients and the documentation that is necessary to prove it will result in decreased reimbursement for the same amount of effort.

Providers should note that the changes to the coding levels applied to Medicare office visits only. Existing 1995 and 1997 E/M regulations would still apply for other services such as hospital visits or for commercial payers. In addition, new payments for certain telehealth services, such as virtual check-ins or prolonged preventative services are also part of the proposed rule.

CMS responds to physician feedback

The backlash to the earlier letter from CMS has produced several results:

  • The January 2019 date for the collapse of level 2-5 codes was initially pushed back to 2021 in order to gain better feedback.
  • According to the American Medical Group Association (AMGA), maintaining the code for more complex-case visits as well as the additional of a two-year window of time should give members time to develop and share recommendations on future changes to A/M.
  • In 2021 CMS will start paying single rates for E/M visits at levels 2 through 4 for both new and established patients and maintaining level 5 to account for patients with multiple conditions or more complex needs.
  • The remainder of the proposed changes will thus far continue to be implemented as originally planned.

How can a billing and practice management service help practices stay current on these changes?

Keeping up with all of these changes, let alone implementing them into your billing cycle, is both challenging and time-consuming. An experienced, comprehensive medical billing service such as M-Scribe is able to take advantage of the latest billing technologies as well as invest in continued training and updating our personnel to ensure that we stay up to date on the latest changes, whether from CMS or other payers.

In business since 2002, M-Scribe offers a complete array of services, from fast-tracking claims follow-up and collections, to help practices grow by boosting their revenues. Contact us at 770-666-0470 or by email to learn more about how easy it can be to stay updated and compliant on the latest coding and reimbursement changes while maintaining a thriving practice.

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