Upcoming E/M Code Changes Will Streamline Medicare Payments

Medicare payments are about to get a whole lot easier for practitioners on January 1, 2019. Early this year the Centers for Medicare & Medicaid Services (CMS) proposed a much needed revamp to the Medicare Physician Fee Schedule. The changes are set to be released in November 2018 and will also include a bunch of modifications to the required documentation of evaluation and management (E/M) visits.

This update to E/M coding is not expected to be a smooth process as the current guidelines have been set in place for over 20 years. Practitioners in all specialties have been waiting for this day of relief from the overly restrictive and non relevant documentation requirements included in the current rules. The voices of CMS are in agreement with the payers:

“Stakeholders have long maintained that both the 1995 and 1997 guidelines are administratively burdensome and outdated with respect to the practice of medicine, stating that they are too complex, ambiguous, and that they fail to distinguish meaningful differences among code levels,”

MedicareCMS continues their statement on the need for change with “In general, we agree that there may be unnecessary burden with these guidelines and that they are potentially outdated … the guidelines have not been updated to account for significant changes in technology, especially electronic health record (EHR) use, which presents challenges for data and program integrity and potential upcoding given the frequently automated selection of code level,”

These proposed changes will streamline payments, reduce administrative requirements and give physicians more freedom to exercise their judgement when it comes to documenting E/M services. In the most simplest terms the changes will eliminate the need to document the history and exam portions of the visit. Under the proposed rule change the only documentation requirement for medicare payment would be the doctors medical decision-making (MDM).

All parties would like to remove the necessity of documenting the history and exam portions. While CMS is onboard of removing this documentation they do hint at additional requirements for documenting MDM. “As long as a history and physical exam are documented and generally consistent with complexity of MDM, there may no longer be a need for us to maintain such detailed specifications for what must be performed and documented for the history and physical exam,” CMS writes in the proposed rule.

In addition to eliminating administrative work, the new changes will also alleviate confusion involved with choosing the correct E/M code for payment. Current Medicare guidelines have always strongly emphasized that MDM is the most important E/M component to use when selecting the appropriate E/M code. These changes will only affect office/outpatient E/M visits.

Physicians simply need to document the reason for visit and amount of time spent face-to-face with patient in order to process the Medicare payment. Practitioners will still have the option of documenting the visit using the old guidelines if they deem necessary. History and exam findings will still need to be documented in the patient’s medical record for other legal reasons.

E/M CodesIn order to streamline medicare payments, CMS wants to change these outpatient and new patient visits to single blended payment rates. The proposal includes a series of add-on codes that could be used for non-procedural specialty recognized services. The new payment rates will greatly simplify the documentation process and improve accuracy.

CMS is encouraging all parties involved to submit comments about the proposed changes. Depending on the feedback that is received there could be a scenario were the changes are not implemented until January 1, 2020. As of now everything looks good to go for final word next month and pave the way for changes to other care settings in future years.

CMS’s final words on these proposed changes are “We believe that revised guidelines could both reduce clinical burden and improve documentation in a way that would be more effective in clinical workflows and care coordination.”

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