CMS and AMA: 2021 proposed changes to E/M outpatient services

Aug. 14, 2019 / By Barbara Aubry, RN

For those involved in coding and compliance, this is not the first time attempted changes to E/M rules have been proposed. Remember 1995 and 1997? Of course, I’m way too young to remember that—ha!

The AMA and others realized rather quickly after the advent of the electronic health record that EHR software was created to mimic a healthcare claim form. This coincided with the misplaced idea that if all the data elements were met, the service would naturally be reimbursed. Another ha! No one talked to the clinicians creating the E/M document in order to understand its real purpose: to document care provided, patient response to care provided, and care planning and/or changes. Is it any wonder most clinicians absolutely hate using a computer that results in “note bloat” as a result of satisfying EHR check boxes?

CMS has become more provider friendly and has proposed several changes to reduce administrative burden on providers and roll back some of the more rigid requirements. The AMA listened, resulting in the AMA proposing revisions to E/M coding as a result of the February 9, 2019 meeting of the CPT Editorial Panel. Panel members approved revisions of the CPT E/M office and other outpatient visit reporting guidelines and code descriptors. AMA reports that this move was in direct response to the leadership displayed by CMS Administrator Seema Verma, who sought revisions to the existing E/M rules to make them more provider friendly and to hopefully reduce burnout.

CMS Conference Call 8/12/2019

CMS seems to be in lock-step with the AMA proposals. During the conference call, CMS reiterated their concern regarding E/M services. They intend to “largely adopt” the AMA proposal for 2021. One slide from the presentation is included below and speaks to the formation of G codes to be used in 2021 to represent additional resources “associated with primary care.” This is important and something we will be monitoring closely:

“In the CY 2019 PFS Final Rule we finalized two HCPCS add-on G-codes describing
additional resources associated with primary care and certain types of non-procedural
specialty visits, for CY 2021:

• However, we understand from previous comments and ongoing engagement with
  stakeholders that the add-on code(s) should be easy to understand and report for
  purposes of medical documentation and billing.

• We also want to maintain clarity that the add-on code is not intended to reflect a difference
  in payment by specialty, but rather recognition of a different per visit resource cost based
  on the kinds of care practitioners provide, regardless of Medicare enrollment specialty.

• We are therefore proposing a single add-on code that describes ongoing primary care
  and/or ongoing medical care related to a single, serious, or complex chronic condition billable with every office/outpatient E/M visit meeting these criteria”

The slides from the CMS presentation can be viewed here. (For in-depth details about the AMA plan and revisions, continue reading. For my perspective, see “My Take” below).

AMA Plan

The AMA plan is focused solely on “revisions to the E/M office or other outpatient visits (CPT codes 99201-99215). The code set revision will be effective 2021. The AMA believes this change is in step with the CMS E/M changes established in 2019:

• Elimination of the requirement to document medical necessity of furnishing visits in the home rather than office
• Elimination of the requirements for clinicians to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated
  • Physicians must only document that they reviewed and verified information regarding the chief complaint and history that is already recorded by ancillary staff or the patient

The AMA commissioned a study of peer-reviewed literature to determine the amount of time that could reasonably be saved once these E/M office visits are implemented. Assuming a conservative reduction of 2.11 minutes per visit, a physician practice who sees 20 patients per day could realize over 180 hours of freed time to focus on patient care.

Additional burden reduction will be seen through:

• Simplifying code selection criteria and making them more clinically relevant and intuitive
• Creating consistency across payers by adding detail within the CPT E/M Guidelines
• Alignment with current documentation guidelines from Medicare and the CPT code set to ensure minimal disruption to practices”

Revisions

1. “Eliminate history and physical as elements for code section: While the physician’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.
   • The Workgroup revised the code descriptors to state providers should perform a “medically appropriate history and/or examination”
2. Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time:
   • MDM: The Workgroup did not materially change the three current MDM sub-components, but did provide extensive edits to the elements for code selection and revised/created numerous clarifying definitions in the E/M guidelines. (See below for additional discussion.)
   • Time: The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM
3. Modifications to the criteria for MDM: The Panel used the current CMS Table of Risk as a foundation for designing the revised required elements for MDM. Current CMS Contractor audit tools were also consulted to minimize disruption in MDM level criteria
   • Removed ambiguous terms (e.g. “mild”) and defined previously ambiguous concepts (e.g. “acute or chronic illness with systemic symptoms”)
   • Also defined important terms, such as “Independent historian”
   • Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external physician/QHP)
4. Deletion of CPT code 99201: The Panel agreed to eliminate 99201 as 99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements
5. Creation of a shorter Prolonged Services code: The Panel created a shorter prolonged services code that would capture physician/QHP time in 15-minute increments. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection”

My Take

I am glad to see that CMS, statisticians and rule makers realized their work, absent clinician input, does not stand the test of time. CMS mentioned during their conference call that 10,000 new beneficiaries are added daily while fewer clinicians are available to care for them. The revisions to E/M and the new reimbursement categories may be one step toward improving those ratios. Adding patients and driving clinicians out of practice does not promote quality health care.

The AMA/CMS revisions make sense—potentially they will force changes in the E/M formats in the EHRs. It will be interesting to see how the EHR format is modified to accommodate the changes and how much that will cost. In my humble opinion, the revisions will not save provider time unless this modification happens. New formats need to be created to mirror E/M requirements rather than claim forms—otherwise, “note bloat” will continue and the revisions will yield little improvement for providers.

I do wonder about their time calculation: “The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service.” Does this mean if the provider uses a particularly onerous EHR and must stay late in the office to complete their notes on the DOS the patient was seen, does this factor into the “time” determination? I understand the creation of care management plans, especially in reaction to the latest proposed CMS plan to require care plans for patients that have only one chronic disease rather than the current minimum of three. These tasks do not require the presence of the patient, but should there be a way to identify time spent in that task versus clinical patient time? I hope the proposed AMA/CMS change includes time providers spend with patients, but if that doesn’t happen, will patients ever see their provider’s face again or only their backs as they populate their EHRs? Perhaps the CMS proposed G codes will clarify this issue.

It will be interesting to see the entire proposal for the changes to calculation of medical decision making (MDM). I’m glad they are removing descriptors such as “mild” which may translate to insignificant in some patients while the same issue in a patient with multiple chronic conditions can be problematic even though the treatment doesn’t differ,. I hope the changes will make determining MDM more rational.

I am pleased to see the prolonged time is proposed to be counted in 15-minute intervals. This is a better representation of provider time, especially since many office visits take fewer than 15 face-to-face minutes.

These are welcome proposals. Unless and until providers feel happy to go to work again, all U.S. healthcare consumers are impacted by the weight of the rules and regulations currently in place.

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.

References:

AMA – https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

CMS Conference Call slide presentation – https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-08-12-PFS-Presentation.pdf

Federal Register – https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-16041.pdf