Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

CMS Delays Collapsing of E/M Payment Rates Until 2021

Implementation of a single E/M payment rate for office visit Levels 2 through 4 won’t go into effect until 2021, CMS stated in the new Physician Fee Schedule rule.

E/M payment rates

Source: Xtelligent Healthcare Media

By Jacqueline LaPointe

- CMS will collapse evaluation and management (E/M) payment rates, but not until the 2021 calendar year, according to the recently released final 2019 Physician Fee Schedule (PFS) rule.

After industry pushback, the federal agency will delay the implementation of a single, blended payment rate for E/M office/outpatient visit levels 2 through 4 for established and new patients. The PFS will maintain the payment rate for E/M office/outpatient visit level 5 to “better account for the care and needs of complex patients,” CMS noted.

To account for the additional resources needed for E/M visits levels 2 through 4, CMS will also offer a new “extended visit” add-on code in 2021. The federal agency will also offer add-on codes for primary care visits and visits for particular types of non-procedural specialized medical care.

The final 2019 PFS rule also paired E/M payment changes with documentation requirement updates. The rule will reduce E/M documentation requirements for all visit levels starting in CY 2019. Documentation changes in the final rule include:

  • Elimination of the requirement to document medical necessity of a home visit in lieu of an office visit
  • Providers can choose to choose their documentation on what has changed since the last visit or on pertinent items that have not changed for established patient visits when relevant information is already documented in the medical record
  • Providers will not have to re-enter information on a patient’s chief complaint and history in the medical record that has already been recorded by an ancillary staff or the beneficiary
  • Removal of potentially duplicative requirements for medical record notations that may have been previously included in the medical records by residents or other medical team members for E/M visits performed by teaching physicians

CMS will continue to reduce E/M documentation burdens into CY 2021. In conjunction with Medicare reimbursement updates, the federal agency will also implement several E/M documentation changes, such as allowing provider to choose to document E/M office/outpatient visits Levels 2 through 5 using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation coding guidelines.

“Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” CMS Administrator Seema Verma stated in an official press release. “Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors. Today’s rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care.”

Providers have praised CMS for proposing to update E/M documentation requirements, but industry leaders have opposed the collapsing of E/M payment rates for office visits.

The American Hospital Association (AHA) said that by “reducing payments for many providers, the proposal to collapse the payment rates for E/M visits devalues providers’ time, increasing the already heavy pressure they face to maximize the number of patients they see each day.”

The AMGA agreed, adding “pairing paperwork reforms with a significant change in categorizing patient complexity and reimbursement may very likely undermine care quality and coordination and cause disruption in physician workflow and referral patterns.”

Despite several industry groups calling for the abandonment of the E/M payment changes, CMS finalized reduced rates for several E/M office/outpatient visit levels. But the federal agency intends for the implementation delay to help providers prepare.

“[The rule] 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,” Verma stated in the press release.

While the final 2019 PFS rule contained major changes to E/M payment and documentation, the rule also included key policy changes intends to modernize Medicare. CMS pointed out that the rule will also:

  • Reimburse providers for two newly define physician services furnished using communication technology (Brief communication technology-based service, e.g. virtual check-in Remote evaluation of recorded video and/or images submitted by an established patient)
  • Expansion of telehealth use for treatment of opioid use disorder and other substance use disorders
  • Pay for communication technology-based services and remote evaluation services furnished by rural health clinics and federally qualified health centers
  • Implement wholesale acquisition cost-based payment for certain Part B drugs

“The historic reforms CMS finalized today move us closer to a healthcare system that delivers better care for Americans at lower cost,” stated HHS Secretary Alex Azar. “Among other advances, improving how CMS pays for drugs and for physician visits will help deliver on two HHS priorities: bringing down the cost of prescription drugs and creating a value-based healthcare system that empowers patients and providers.”

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