Brace Yourself: CMS Wants to Completely Overhaul Your E/M Coding

Not everyone is pleased with the proposed flat-fee concept

Between the recent release of new ICD-10-CM  and ICD-10-PCS codes and the upcoming 2019 CPT and Medicare changes, you’re probably feeling overwhelmed. Get ready for more big changes, however, because the Centers for Medicare & Medicaid Services (CMS) is now looking to revamp the Medicare Physician Fee Schedule (PFS) – and completely change your Evaluation and Management (E/M) coding.

Auditors have been taking a hard look at claims to ensure documentation supports the E/M level of service charged, according to orthopedics coding experts Margie Scalley Vaught and Lynn Anderanin in their Virtual Boot Camp orthopedics-focused specialty sessions. But all your E/M coding rules could soon change, if the federal government pushes through a new proposed rule.

E/M Coding Proposal: From 5 Levels to 2, Flat Pay Rate

The scoop: Recently, CMS published a proposed rule in the July 27 Federal Register that would revise payment policies under the PFS for Part B, beginning in 2019. The proposed rule has a public comment period that’s open until Sept. 10, 2018.

Perhaps the most significant – and certainly the most talked about – change in the proposed rule is CMS’s plan to overhaul E/M codes. Instead of coding E/M services in one of five category levels, CMS proposes to “collapse” Level 2 through Level 5 and provide a flat pay rate, according to a MedPage Today report.

You would still have separate filing systems for new versus established patients, and the flat fee per office visit would be the same for all physician specialties, reported Becker’s Spine Review. Physicians who need to spend more time with patients can file for an “add-on” payment of $67 per visit.

You would use the 1995 or 1997 E/M elements, medical decision making (MDM), or time to determine a visit’s E/M level, according to the American Association of Orthopaedic Executives (Reimbursement for a new patient visit (Level 2 through 5) would be $135, while a visit with an established patient would be $93.

Will Paperwork Reduction Be Worth a Possible Pay Cut?

Potential benefits: The whole idea behind this E/M billing overhaul is to reduce the amount of time physicians spend documenting the patient’s family, social and medical history, especially re-documenting history already covered in a prior visit or with a previous provider. Physicians would need to document only what transpires during the visit itself and any new problems or new aspects to a patient’s history, CMS Chief Medical Officer Kate Goodrich said during a July 26 panel discussion on E/M coding reform.

CMS stated that the changes would reduce audit burden, eliminating the need to scrutinize visit levels, according to a report by attorney Jennifer Breuer, a partner with Drinker Biddle & Reath LLP. “CMS believes a single payment rate also will eliminate the increasingly outdated distinction between the kinds of visits reflected in the current CPT code levels in both the coding and the associated documentation rules.”

Outlook: Considering the potential impact of valuing E/M Levels 2 through 5 together, with the additional adjustments, Breuer’s report illustrated CMS’ projections that orthopedic surgery would experience a minimal change to overall payment. Specialties like podiatry and dermatology may fare the worst, with an estimated 4-percent decrease in overall payment, while some specialties like obstetrics/gynecology may actually benefit from the E/M coding reform, with a projected 4-percent increase.

Historic Effort? Not Everyone Thinks So

Of course, reactions to the proposed changes from stakeholders and physicians are somewhat mixed, although many are apprehensive. Stakeholders and Medicare advocates like the Medicare Rights Center are urging CMS to postpone the E/M coding changes and consider doing a trial run first, NPR reported. If finalized, the rule would become effective Jan. 1, 2019.

Bottom line: Now more than ever, you’ll need to understand 1995 versus 1997 E/M elements and how they can make a difference in auditing, Vaught stressed. You also need to brush up on when auditors might suspect “cloning” and how to spot the MDM essentials – the “meat and potatoes” of full documentation, as these topics will be increasingly crucial to surviving the E/M coding reform to come.

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