CMS: Evaluation and Management (E/M) coding changes proposed

July 23, 2018 / By Barbara Aubry, RN

I don’t know about you, but my head is spinning. On July 12, 2018, Administrator Verma released an email with some pretty stunning news. I’m going to focus on the proposed E/M coding changes in this blog. CMS proposes:

Streamlining E/M Payment and Reducing Clinician Burden:

CMS and the Office of the National Coordinator for Health Information Technology have heard from stakeholders that CMS’ extensive documentation requirements for E/M codes have resulted in unintended consequences. To meet these documentation requirements, providers have to create medical records that are a collection of predefined templates and boilerplate text for billing purposes, in many cases reflecting very little about the patients’ actual medical care or story.

Responding to stakeholder concerns, several provisions in the proposed CY 2019 PFS would help to free EHRs to be powerful tools that would actually support efficient care while giving physicians more time to spend with their patients, especially those with complex needs, rather than on paperwork. Specifically, this proposal would:

– Simplify, streamline and offer flexibility in documentation requirements for E/M office visits—which make up about 20 percent of allowed charges under the PFS and consume much of clinicians’ time

– Reduce unnecessary physician supervision of radiologist assistants for diagnostic tests

– Remove burdensome and overly complex functional status reporting requirements for outpatient therapy”

On July 19, 2018, I attended the CMS Open Door Forum call for clinicians. During the call, it was stated that the changes are being proposed to “increase flexibility for clinicians to focus on the clinical relevance of the visit.” CMS provided additional information on the proposed E/M coding changes below:

  • The proposed E/M code assignment will be based on medical decision making or time spent. Time spent can be used without the need for care coordination or counseling as the main reason for the visit. The time spent must still be face-to-face time with level 2 MDM requirements
  • Documenting expanded history is important; CMS expects providers to focus on “what changed since the last visit”
  • Providers need to verify (in writing) the data added to the record by ancillary staff
  • Currently ancillary staff can only enter ROS (review of systems) CMS proposes to allow them to also document chief complaint (CC) and likely history
  • Documentation guidelines will be changed in future to pay levels 2-5
  • Single base payment rate for new vs established services
  • Possibility of new add on E/M codes for specialists (New)
  • Providers must maintain documentation standard of at least a level 2 history, exam and medical decision making (MDC) when coding current and future work
  • Create new E/M codes for podiatry (New)
  • E/M with procedure; create procedure adjustment for E/M which likely reduces the payment for the E/M on the same DOS (New)
  • New code for prolonged face-to-face E/M code (New)
  • Keeping modifier 25
  • Blended payment for E/M comes to the value of a level 3.6. This will be a problem for those who usually bill a level 4 or 5
  • They will maintain the MDM using the current parameters but are looking for suggestions for future improvements

My Take

I’m glad to see some changes in the E/M coding requirements since it’s been 20+ years since they were originally published. I believe we have the EHR vendors to thank for this change, since clinicians are so disappointed about the functionality of most of them. Years ago when the momentum was beginning, I was very surprised to see the designs—certainly not clinically friendly. The E/M templates the vendors built required much more documentation than was appropriate for many services. Was this an effort to allow for billing higher level Evaluation and Management services since literally every data point was added and re-added infinitum? I’ve always wondered why if clinicians are to use the tool, they would agree to a template that mimics a level 5 E/M documentation—especially since it was known the greatest portion of E/M services are a level 3. Perhaps the proposed users were not consulted?

CMS finally heard the complaints from providers regarding their belief that the systems were designed for billing purposes and not clinical practice. As I understand it, CMS’ goal is the reduction in the complexity of documentation to a level appropriate for clinical purposes. They believe this will (hopefully) reduce the amount of time physicians spend documenting and administrative costs as well.

These are important proposed changes, including the suggested “blended payment rate” which according to CMS, averages an E/M level 3.6 value. A question was raised during the call from neurological surgeons wondering how reimbursement for their E/M levels 4 and 5 services for very complex cases will be impacted. We will have to wait and see.

If you have questions, or suggestions CMS reiterated multiple times during the call that they must be received by CMS no later than September 10, 2018.

For more information:

The Proposed Rule

CMS Fact Sheet

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