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CMS Finalizes and Delays Proposed Changes to E&M Services Coding

on Wednesday, 5 December 2018 in Health Law Alert: Erin E. Busch, Editor

In November 2018, CMS issued its final rule for the Medicare Physician Fee Schedule. In a previous article, we had summarized the changes to E&M coding that CMS had proposed in its July 27, 2018 proposed rule. In this final rule, CMS delayed until 2021 any changes to reimbursement for E&M codes to allow for additional comments and further preparation to implement changes.

In commenting on the delay in the effective date, CMS Administrator Seema Verma stated, “We know that this is going to have a tremendous impact on many doctors in America, and we want to make sure we get this right.” CMS noted the additional time will allow additional refinements to the intended changes.

CMS adopted certain changes that will be effective next year (2019), including:

  • Eliminating the requirement to document the medical necessity of a home visit in lieu of an office visit
  • For established patient visits, allowing physicians and other practitioners to focus their documentation on what has changed since the last visit; however, CMS notes that physicians and other practitioners should still review prior data, update it as necessary, and indicate in the medical record that they have done so;
  • Permitting physicians and other practitioners to forego reentering into the medical record the patient’s chief complaint and history when it has already been entered by staff or the patient, noting that the physician or other practitioner can simply note that this information was reviewed and verified; and
  • Revising documentation requirements for teaching physicians, including permitting medical residents or nurses to document the presence and extent of the teaching physician’s participation during an E&M visit, rather than requiring the teaching physician to complete the documentation.

In the changes to be effective in 2021, CMS changed its approach to bundling for E&M visits by excluding Level 5 visits, as well as Level 1 visits, from the bundled payment amount. CMS stated that it was making this change to better account for the needs of complex patients and the services being provided to those patients. As a result, in 2021, there are three payment levels for E&M visits for both new and established patients, as follows

  1. 99201 – Level 1 new patient office visit
  2. 99202 through 99204 – Levels 2 through 4 new patient office visit
  3. 99205 – Level 5 new patient office visit
  4. 99211– Level 1 established patient office visit
  5. 99212 through 99214 – Levels 2 through 4 established patient office visit
  6. 99215 – Level 5 established patient office visit

Additional changes relating to E&M coding incorporated into the final rule, to be effective in 2021, are:

  • Permitting physicians and other practitioners to choose to document E&M visits using medical decision-making (“MDM”) or time instead of utilizing the current 1995 or 1997 E&M documentation guidelines, if desired;
  • Reducing documentation burdens by allowing a physician or other practitioner using MDM or current E&M documentation guidelines to satisfy documentation requirements by having minimum supporting documentation typically associated with a Level 2 visit for history, exam and/or MDM elements for Level 2 through 4 visits;
  • Permitting physicians and other practitioners using time to code E&M services to satisfy documentation requirements by documenting the medical necessity for the visit and that the billing physician or other practitioner personally spent the required amount of time face-to-face with the patient;
  • Clarifying that the use of add-on codes for additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care for office visits (Levels 2 through 4) would not be restricted by physician specialty and would not impose new per-visit documentation requirements; and
  • Adopting a new “extended visit” add-on code for use only with E&M office visits (Levels 2 through 4) to account for additional effort when physicians and other practitioners are required to spend extended time with the patient.

The final rule can be found here.

Kimberly A. Lammers

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