Levelling the E/M Playing Field: CMS Proposes Solution to Guideline Confusion

Posted on 1 Nov, 2018 |comments_icon 0|By Bruce Pegg

If you routinely document evaluation and management (E/M) services, you’ve probably been waiting anxiously since July for the Centers for Medicare and Medicaid Services (CMS) to release the 2019 Medicare Physician Fee Schedule Final Rule to see if the proposed changes to the E/M guidelines will be enacted and what they will finally look like. Now that the comment period on CMS’s proposal has ended, and publication of the Final Rule is just weeks away, we take one more look at what CMS has put on the table and how it might affect Medicare reimbursement beginning on Jan. 1, 2019.

Blended Payments and Add-On Codes

The main area of concern for coders, billers, and office managers across all outpatient specialties is the proposal for “new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services,” according to the CMS Fact Sheet “Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019.”

What this would do to your bottom line has been unclear from the start. CMS has proposed fixing rates for new patient visits at $44 for 99201 and $135 for 99202-99205 and established patient rates at $24 for 99211 and $93 for 99211-99215. To offset the decrease in reimbursements, especially for level-three and level-four visits, CMS also proposed “HCPCS G-code add-ons to recognize additional relative resources for primary care visits and inherent visit complexity that require additional work beyond that which is accounted for in the single payment rates for new and established patient levels 2 through level 5 visits” and “an additional prolonged face-to-face services add-on G code,” according to the 2019 PFS proposed rule.

Taming the Beast of Administrative Burden

To further sweeten the deal, CMS has promised a long-needed overhaul of E/M documentation requirements, which would hopefully reduce the time you spend coding, and your provider spends documenting, sick visits. In all, CMS is proposing

  • Allowing you to use the current outpatient E/M guidelines or to use either medical decision making or time to document visits;
  • Allowing you to use of time “as the single factor in all E/M visits, not just when counseling or care coordination dominate a visit” (Source: 2019 PFS proposed rule);
  • Allowing your documentation to focus “on what has changed since the last visit or on pertinent items that have not changed rather than re-documenting information,” providing the physician reviews and updates previous information (Source: “Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019”); and
  • Allowing your provider to review, rather than re-enter, items in the patient’s medical record that either the patient or practice staff has previously entered.


The $64,000 Question

Will the sweeping changes be adopted, either whole or in part? Or will CMS need more time to evaluate the public comments before deciding the best way to move ahead?

If the sheer volume of comments, from the major professional healthcare organizations on down, is anything to go by, changes to the E/M guidelines in 2019 won’t be as radical as originally proposed, if they even happen at all. While praising the parts of the proposal that advocate reducing paperwork, for example, the American Medical Association, along with 170 professional associations and medical groups nationwide, is highly critical of the suggested two-tiered restructure of E/M levels. The American Academy of Family Physicians follows suit in a separate 80-page critique, as does the American Academy of Professional Coders in their comments to CMS.

Fortunately, we won’t have to wait too much longer to find out what the new E/M guidelines will look like. And as soon as the Final Rule is announced, we’ll be here to let you know if, and how, it will affect you and your practice.

Learn More

Get up to speed on current Medicare regulations and secure your revenue with TCI’s best-selling Medicare Compliance and Reimbursement Insider 2018. Packed with vital compliance and reimbursement guidance — as well as Clip-and-Save tools, readers’ Q&A, case studies, and field-tested best practices — you’ll lock down compliance, master clean claim submissions, and hold onto every well-earned dollar of reimbursement.

Get the latest E/M news and reimbursement guidelines, uncover answers to your E/M coding and documentation questions, and find the help you need to secure your deserved pay with a monthly, risk-free subscription to E/M Coding Alert.

Don’t risk lost revenue for your E/M services. Safeguard your practice against claim denials and audit scrutiny with TCI’s Evaluation & Management Coding Handbook 2018. Our experts take on a myriad of E/M challenges you’re facing and give you solutions with real-world coding scenarios to build your E/M know-how and equip you to code the correct level of service every time.


Bruce Pegg
Editor, Newsletters

An experienced teacher and published author, Bruce is TCI’s new voice of primary care, delivering advice and insights every month for coders in the fields of family, internal, and pediatric medicine through Primary Care Coding Alert and Pediatric Coding Alert. Additionally, he is the current editor of E/M Coding Alert. Bruce has a Bachelor of Arts degree from Loughborough University in England and a Master of Arts degree from The College at Brockport, State University of New York. He recently became a Certified Professional Coder (CPC®), credentialed through AAPC.

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