Providers Praise E/M Documentation Changes, Oppose Payment Plans

August 29, 2018 - Physicians and other healthcare professionals recently welcomed proposed evaluation and management (E/M) documentation changes from CMS that would reduce administrative burden and streamline Medicare billing.

Specifically, the American Medical Association (AMA), American Academy of Family Physicians (AAFP), American Academy of PAs, and over 160 other industry groups commended CMS for proposing changes to the required documentation of a patient’s history. The proposal would allow E/M documentation to focus only on the interval history since the previous visit.

Two other proposed E/M documentation changes in the 2019 Medicare Physician Fee Schedule rule also earned approval from the groups. Those were the removal of the requirement for physicians to re-document information that has already been included in the patient’s record by practice staff or the patient himself and the elimination of the need to justify a home versus office visit.

“Implementation of these policies will streamline documentation requirements, reduce note bloat, improve workflow, and contribute to a better environment for healthcare professionals and their Medicare patients,” the groups wrote to CMS Administrator Seema Verma.

While over 160 physician and healthcare professional advocates called for the immediate adoption of the proposed E/M documentation changes, the groups also raised concerns with other aspects of the proposed 2019 Medicare Physician Fee Schedule rule.

READ MORE: Maximizing Revenue Through Clinical Documentation Improvement

In particular, the groups questioned the proposal to reduce the number of payment rates for eight office visit services for new and established patients down to two each.

In the proposed rule, CMS put forth a payment policy that would create single blended payment rates for new and established patients for office/outpatient E/M levels 2 through 5 visits. The payment policy would also create add-on codes to account for the resources used to deliver primary care and non-procedural specialty generally recognized services.

CMS intends for the proposed payment policy for E/M visits to improve Medicare reimbursement accuracy and simplify medical billing documentation.

However, the physician groups stated that the proposed payment changes could potentially harm providers and other healthcare professionals who treat the sickest patients and who deliver comprehensive primary care.

Finalizing the payment policy could hurt certain physicians and professionals. Ultimately, the policy would decrease patient access to care, the groups stressed.

READ MORE: Exploring the Fundamentals of Medical Billing and Coding

A coalition of 126 patient and provider groups led by the American College of Rheumatology agreed with the physician and healthcare professional groups. Their letter to CMS elaborated on how the proposal would harm physicians treating medically complex patients.

“The proposals to consolidate the billing codes for physician evaluation and management so as to pay the same amount for office visits regardless of the complexity of the patient would cut payments for visits that are currently reimbursed at higher levels than simple or routine office visits, penalizing doctors who treat sicker patients or patients with multiple conditions,” the coalition explained. “It is important to note that even small estimated changes in reimbursement will be magnified after physicians or their employers cover overhead business expenses.”

Both letters also detailed several other concerns with the proposed payment changes for E/M visits. The physician and healthcare professional groups urged CMS not to adopt the new multiple service payment reduction policy because “the issue of multiple services on the same day of service was factored into prior valuations of the affected codes.”

Under the proposed 2019 Medicare Physician Fee Schedule rule, CMS would implement a multiple procedure payment adjustment for certain visits. The federal agency designed the payment policy to “recognize efficiencies that are realized when E/M visits are furnished in conjunction with other procedures.”

But the proposal could negatively impact specific services offered by specialists, the groups explained. The policy may unintentionally change the current practice expensive methodology for vital services, such as chemotherapy administration.

READ MORE: The Difference Between Medicare and Medicaid Reimbursement

The proposal could also have the unintended consequences of reducing direct patient time and increasing the financial burden on patients, the coalition of patient and provider groups added.

“To offset the reimbursement cut, some physicians may spend less time with their patients and limit each office visit to one or two problems forcing patients to return for a second additional visit to address additional medical issues,” the coalition wrote.

“Not only will this result in an additional burden on patients with more copayments and costs associated with time and travel, it will also reduce the quality of care, particularly for patients with complex medical conditions,” the letter continued.

The coalition also expressed concerns that the reduced reimbursement rates would incentivize physicians to cherry-pick healthy patients.

The industry groups urged CMS to abandon the proposed E/M payment changes. Instead, the federal agency should support the AMA’s creation of a workgroup dedicated to defining and valuing codes, the physician and healthcare professional groups advised in their letter.

The AMA intends to develop a workgroup of physicians and healthcare professionals who are coding experts. The workgroup could consist of professionals who use office visit codes to describe and bill for services delivered to Medicare patients.

Using their expertise and experience, the workgroup could analyze E/M coding and payment challenges to develop solutions that CMS can implement by the 2020 Medicare Physician Fee Schedule.

“A number of CMS personnel monitored the initial conversations of the workgroup and we look forward to their active participation in this process going forward,” the groups wrote.

By partnering with the workgroup and the medical community at large, CMS should be able to create a “mutually agreeable policy that will achieve our shared goal of simplifying E/M documentation burdens while mitigating any unintended consequences,” the letter concluded.