Physician groups hope to work with CMS on E/M implementation, ensure fair reimbursement

With a two-year delay on implementation of a new coding and payment structure for Medicare patients’ office visits, physician groups say they hope to work with the Centers for Medicare & Medicaid Services (CMS) to ensure doctors are fairly paid.

CMS Thursday issued a final rule (PDF) for the Medicare 2019 physician fee schedule that put the streamlining of E/M payments on hold until 2021—a move welcomed by many physician groups.

The American Academy of Neurology called the decision by CMS to delay the collapse of E/M codes until 2021 “a win for neurology” and said it will continue to fight to maintain fair reimbursements for physicians who care for the most complex patients.

“We fought these misguided proposals and are pleased that CMS has listened to our concerns and delayed implementation of compressed E/M payments. We still have work to do to maintain fair pay,” said Ralph L. Sacco, M.D., AAN’s president in a statement.

The group hopes to develop a modified E/M structure, but just how far CMS officials will go in changing its proposal remains to be seen.

In a conference call Thursday where she announced the changes, CMS administrator Seema Verma said the two-year delay should not be viewed as an indication the agency would scrap its changes and restore the existing five-level E/M payment system.

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CMS did modify it’s E/M structure from what was announced in a proposed rule last July. Instead of collapsing E/M codes in levels 2 through 5—which indicate the complexity of services physicians provide—CMS will consolidate levels 2 through 4 and keep level 5, used for the sickest patients. Therefore, the E/M coding and payment structure will remain unchanged in 2019 and 2020.

The Association of American Medical Colleges said CMS had acknowledged the concerns about the importance of appropriate payments for complex patients. “Physicians who are associated with medical schools and teaching hospitals treat many patients with complex needs, and we look forward to working with CMS to ensure that payments accurately reflect the resources and effort needed to care for these patients,” said Darrell G. Kirch, M.D., AAMC’s president and CEO, in a statement.

AMGA, a group that supports the move to value-based care, said CMS’ original proposal would have disrupted physician workflow and referral patterns. “AMGA members were very concerned that CMS was moving too aggressively in its plan to streamline the payment and coding for E/M office visits, particularly those providers who treat a large number of complex patients,” said AMGA President and CEO Jerry Penso, M.D., in a statement. “Maintaining the code for the most complex patient visits somewhat alleviates that concern.”

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The American College of Rheumatology (ACR) said CMS took into account concerns of stakeholders. “The ACR appreciates that CMS is valuing input from physician and patient stakeholders and we will continue to work with stakeholders on ways to make healthcare more accessible and affordable for the 54 million Americans living with rheumatic disease,” the group said in an emailed statement.

The Community Oncology Alliance (COA) also said it was on board with most of the changes made by CMS. “CMS Administrator Seema Verma and staff have largely listened and responded to feedback, resulting in a final rule that for the most part is good for patients and their providers,” the group said.

CMS received over 15,000 comments in response to its proposed rule. “CMS acknowledges the thousands of comments received in response to their proposal to update E/M codes by finalizing the reduced documentation requirements, while delaying the proposed payments changes until 2021,” said Don Crane, president and CEO of America’s Physician Groups.

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CMS touted the E/M changes as a way to cut doctors’ paperwork burden and the agency decided to implement several proposals to provide physicians with documentation relief in 2019. “Additional flexibility in how care is documented allows providers to focus on their patients, not their computers,” said the AMGA’s Penso. The changes include:

• Eliminating the requirement to document the medical necessity of a home visit in lieu of an office visit.
   
• For established patients, when relevant information is already in the medical record, practitioners can focus documentation on what has changed since the last visit. Practitioners don’t need to re-enter the defined list of required elements if there is evidence they have reviewed and updated the previous information as needed.
   
• Physicians will also not have to re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient.
   
• CMS is also removing the requirements for notations in medical records that may have previously been included by residents or other members of the medical team for E/M visits furnished by teaching physicians.

Physician groups also applauded CMS’ decision not to implement a proposal to reduce payment for same day E/M services and procedures, a move COA worried would unnecessarily disrupt patient care. CMS originally planned to apply a multiple procedure payment reductions to E/M visits furnished on the same day as a procedure. Payment rates for the cheaper of the two will be maintained, rather than halved, as was initially proposed, said the AAN.