CMS finalizes E/M changes in its “Dear Clinician” letter

Nov. 12, 2018 / By Barbara Aubry, RN

On November 8, 2018 CMS released its Dear Clinician letter providing final decisions on the proposed Evaluation and Management coding changes discussed in a previous blog. The letter is a further example of the role CMS is adopting as a provider-friendly organization. It “sought to update the documentation requirements and propose a new model of payments for E/M services” while acknowledging receipt of more than 15,000 comments which “reaffirmed the need to reduce burden on clinicians and provided us with specific feedback on how to improve our proposal.” Per CMS:

“Effective January 1, 2019 we will:

• Simplify the documentation of history and exam for established patients such that when relevant information is already contained in the medical record, clinicians can focus their documentation on what has changed since the last visit rather than having to re-document information.
• Clarify that for both new and established E/M office visits, a Chief Complaint or other historical information already entered into the record by ancillary staff or by patients themselves may simply be reviewed and verified rather than re-entered.
• Eliminate the requirement for documenting the medical necessity of furnishing visits in the patient’s home versus in an office.
• Remove potentially duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team.

Beginning in 2021, we will implement payment and coding changes to achieve additional burden reduction. Billing for visits will be simplified and payment will vary primarily based on attributes that do not require separate, complex documentation. For 2021, we intend to:

• Implement a single payment rate for visits currently reported as levels two, three, and four. These represent a majority of office/outpatient visits with clinicians. This means that for the majority of visits, the required documentation related to payment will be limited to what is required for a level two visit.
• Retain a separate payment rate for the most complex patients—those currently reported through use of the level five codes. Also we will retain the current separate code for level one visits, which are predominantly used for visits with clinical support staff.
• Introduce coding that adjusts rates upward to account for additional resource costs inherent and routine in furnishing certain types of non-procedural care. These codes would only be reportable with level two through four visits, and their use generally would not impose new per-visit documentation requirements. 
• Introduce coding that adjusts rates upward for use with level two through four visits to account for the additional resource requirements when practitioners need to spend extended time with a patient.
• Allow for flexibility in how level two through five visits are documented—specifically introducing a choice to use the current framework, medical decision-making, or time.”

My Take

It’s a beginning!

CMS also acknowledged that this remains a work-in-progress and will continue the dialog with clinicians on the changes. I hope we get clarification of the documentation expected under the new system. When a clinician is required to “review and verify” data entered by support staff or the patient, exactly what does the verification look like? Will the current “signature requirements” (legible name including credential and date) be sufficient?

I believe removing the burden of entering a ton of redundant data in the EHR is a good idea and hopefully reduces a lot of “clerical time” that would be better spent delivering clinical services to patients.

There will be coding changes put in place by 2021 to identify additional time spent on E/M services in Levels 2-4. Specifically, CMS says “adjusts rates upward to account for additional resource requirements when practitioners need to spend extended time with a patient” and will likely be in the form of some type of new HCPCS codes. This may ease the concerns of clinicians facing a flat reimbursement for Levels 2-4. I hope CMS realizes a flat rate can generally be appropriate in certain circumstances, but there are many instances when two patients with the same diagnosis receiving the same E/M service have vastly different needs. Often the root cause of the time differentiation in patient management is due to psycho social needs and/or family dynamics and presence or absence of adequate patient/community support.

If CMS continues the conversations they are having with clinicians, I predict the changes will be reasonable. Just looking at claims data is not enough. Stay tuned….

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