Now that the dust has settled from the release of the Physician Fee Schedule Final Rule, maybe it’s time for a re-cap. This article will also discuss CodingIntel’s survey results. Thank you for taking the time to complete the survey.
CMS postponed the most radical, jaw dropping proposals.
In fact, CMS said that it would continue to work with the AMA’s CPT committee in the next two years, and so I don’t think even these adopted proposals for 2021 are set in stone.
In the final rule, CMS said
“We note that the 2-year delay in implementation will provide an opportunity for us to respond to the work done by the AMA and the CPT Editorial Panel, as well as other stakeholders. We will consider any changes that are made to CPT coding for E/M services, and recommendations regarding appropriate valuation of new or revised codes, through our annual rulemaking process.”
Highlights for 2021 postponed E/M rules
- Single payment and single RVU values for new patient visits level 2-4; this was revised from the proposed rule that initially had a single payment and value for levels 2-5
- Single payment and single RVU values for established patient visits level 2-4; this was also revised from a single value for codes 2-5
- New, minimal documentation requirements, including an options to use medical decision making only, meeting the MDM requirements for a level 2 visit
- Revision to time rule
- Add-on HCPCS code for inherent complexity related to certain types of specialty services
- Add-on HCPCS code for inherent complexity for performing primary care services
- Adding a HCPCS code for prolonged services defined as 15-30 minutes
- The AMA could develop CPT codes to replace these proposed HCPCS codes for 2018
Burden reduction for E/M services—effective January 2019
This was the subject of the survey that I sent out. I wondered how your practices plan to implement CMS’s burden reduction practices, in light of the fact that these are codified in CPT. And, that the MACs haven’t had time to update their FAQ sections of their websites on E/M services. Here is what CMS is allowing. These apply to 99201—99215 only.
- For new or established patients, information documented in the HPI by ancillary staff will not need to be re-documented by the billing practitioner, as long as it is reviewed and verified, and that review and verification is documented
- Simplify history and exam documentation. Here is a quote from S Verma, CMS’s administrator, describing that. “Simplify the documentation of history and exam for established patients such that when relevant information is already contained in the medical record, clinician can focus their documentation on what has changed since the last visit rather than having to re-document information.”
- Practitioners would still be required to review medically necessary elements of the history and physical exam previously documented, but would not need to re-record those elements, if there is evidence the practitioner reviewed and updated the prior information
- It will no longer be required to document the medical necessity for home visits
- The burden for teaching physicians was reduced, but until CMS updates its manual, it isn’t clear to me what that reduction is
But, before we start the celebration, there was a FAQ from CMS in November. You can see it for yourself here.
In case you don’t want to click, here it is in its entirety. I’ve underlined the last sentence, which it seems to me, partially contradicts the other CMS statements.
November 26, 2018
Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) Physician Fee Schedule (PFS)
This document addresses Frequently Asked Questions (FAQs) regarding documentation and payment for evaluation and management (E/M) visits under the Medicare Physician Fee Schedule (PFS).
- What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019?
The CY 2019 PFS final rule expanded current policy for office/outpatient E/M visits starting January 1, 2019 to provide that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that she or she has done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (History of Present Illness (HPI), Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits. To clarify terminology, we are using the term “history” broadly in the same way that the 1995 and 1997 E/M documentation guidelines use this term in describing the CC, ROS and PFSH as “components of history that can be listed separately or included in the description of HPI.” This policy does not address (and we believe never has addressed) who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.
So how are we going to audit in 2019? Are we going to teach one thing for documenting office visits for Medicare patients and one thing for non-Medicare patients? Are we going to audit them differently?
The survey results surprised me. 66 people took the time to answer the survey. The results weren’t entirely consistent. Probably the survey was too soon after the rule, for many groups to have time to discuss their current policy, with other departments and come up with a consistent plan.
|Have you changed the way you educate practitioners about E/M? Or will you in the near future?||48%||52%|
|Have you changed your auditing policy? Or will you in the near future?||47%||53%|
|For established patients, are you changing your audit policy to allow practitioners to verify and use history from a prior visit in this way, without re-documenting it for Medicare patients?||40%||60%|
|For established patients, are you changing your audit policy to allow them to verify and use exam from prior visit in this way, without re-documenting it for Medicare patients?||24%||76%|
|Are you going to have different auditing policies for Medicare and non-Medicare patients?||20%||80%|
|CMS says that now the provider doesn’t need to re-document the HPI taken by a staff member, as long as it is reviewed and verified. What are you doing about that?|
|We are still requiring the billing practitioner to document the HPI||49%|
|We are allowing the billing practitioner to verify (not re-document) the HPI for Medicare patients only||13%|
|We are allowing the billing practitioner to verify (not re-document) the HPI for all patients||38%|
Moving forward | E/M in 2019
Most practices and health care organizations haven’t had time to develop new policies, since the Final Rule was released in November. Let’s gather data in the first quarter of 2019. Have the MACs updated the FAQ page for E/M services? Have any other payers indicated they will change their policies, or will they continue to follow CPT rules. Payers don’t have to follow Medicare changes, and although they often do, there is no mandate to do so.
And then, each practice and health care organization will need to update, formally or informally, how to audit E/M services, and decide whether to use a different set of rules for Medicare patients.