Proposed Medicare fee schedule aims to simplify E/M documentation
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Carol Hoppe, CPC, CCS-P, AAPC Approved Trainer, is available to assist ISMA members with questions on the Medicare 2019 fee schedule changes, E/M coding and documentation requirements or other practice management and billing questions. A health care educator and consultant at MedLucid Solutions, LLC, Carol is the author of ISMA’s four-part webinar series, “Will Your E/M Coding & Documentation Survive an Audit?”  To be put in touch with Carol Hoppe, contact ISMA. Please do not email any PHI.
The Centers for Medicare & Medicaid Services (CMS) unveiled its proposed 2019 Medicare Physician Fee Schedule (PFS) Rule on Thursday, July 12. The American Medical Association (AMA) is reviewing the proposed changes. Terri Marchiori, AMA director of federation relations, said in an email that the AMA will prepare a summary of the proposed rule for federation members and will collaborate with them on comments to submit to CMS by the Sept. 10 deadline.

Key provisions of the rule would affect the Quality Payment Program (QPP), the Merit-based Incentive Payment System (MIPS), and the PFS in 2019: 
  • With the budget neutrality adjustment to account for relative value changes, as required by law, the proposed 2019 PFS conversion factor is $36.05, a slight increase from the 2018 PFS conversion factor of $35.99.
  • CMS has proposed several coding and payment changes to reduce the administrative burden on physicians and improve payment accuracy for Evaluation and Management (E//M) visits by:
    • Allowing practitioners to choose to document office/outpatient E/M visits based on 1) medical decision-making, 2) time, or 3) the current 1995 or 1997 E/M documentation guidelines. CMS is soliciting comment on how documentation guidelines for medical decision-making might be changed in the future.
    • Applying a minimum documentation standard, where Medicare would require information to support a level 2 CPT visit code for history, exam and/or medical decision-making in cases where practitioners choose to use the current framework.
    • Expanding current options by allowing practitioners to use time as the governing factor in documenting and selecting the E/M level, regardless of whether counseling and/or care coordination dominates the visit.
    • Blending payment for new patient office visits (99202-99205) to $135 and established patient office visits (99212-99215) to $93. New codes would be created to provide add-on payments to office visits for specific specialties ($9) and primary care physicians ($5).
    • Expanding current options regarding the documentation of history and exam, to allow practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update previous information.
    • Allowing practitioners to simply review and verify certain information in the medical record that is entered by ancillary staff or a beneficiary, rather than re-entering it.
    • Implementing a 50% multiple procedure reduction for the lower paid service when physicians report an E/M service and a procedure on the same date.
    • Implementing new CPT codes and payment for remote monitoring and interprofessional consultations.
    • New coding for podiatry E/M visits that would more specifically identify and value these services. CMS also proposes a new prolonged face-to-face E/M code and a technical modification to the practice expense methodology.
    • Eliminating the requirement to justify medical necessity of a home visit in lieu of an office visit.
    • Soliciting public comment on potentially eliminating a policy that prevents payment for same-day E/M visits by multiple practitioners in the same specialty and group practice.
    • For E/M visits furnished by teaching physicians, CMS also proposes to eliminate potentially duplicative requirements for notations in medical records that may previously have been included in the medical records by residents or other members of the medical team. 
    • Updated supplies and equipment pricing. The re-pricing of antigens has a significant impact on allergy and immunology payments, with an estimated 6% reduction for the specialty.
Here are some highlights of the Merit-based Incentive Payment System (MIPS) proposals for 2019, according to the AMA:
  • Retaining the low-volume threshold, but adding a third criterion of providing fewer than 200 covered professional services to Part B patients.
  • Retaining bonus points for:
    • Care of complex patients;
    • End-to-end reporting; and
    • Small practices.
  • Allowing eligible clinicians to opt in if they meet one or two, but not all, of the low-volume threshold criteria.
  • Consolidating the low-volume threshold determination periods with the determination period for identifying a small practice.
  • Eliminating the base and performance categories and reducing the number of measures in the Promoting Interoperability category.
  • Requiring eligible clinicians to move to 2015 CEHRT certified EMR technology.
  • Providing the option to use facility-based scoring for facility-based clinicians.
  • For the 2019 performance year, the weights are:
    • Quality – 45%
    • Cost – 15%
    • Promoting Interoperability – 25%
    • Improvement Activities – 15%
A summary and analysis of the changes from the American Hospital Association is online here.

CMS fact sheets summarizing the major components of the proposed rule are available here and here. 
The specialty impact table from the rule is available here.