CMS Proposed Evaluation and Management (E/M) Changes

The Calendar Year 2019 Medicare Physician Fee Schedule proposed rule has several changes, including changes in the way Evaluation and Management (E / M) encounters are paid.

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In the current format, the visits are categorized as new or established and include five different levels of care in each category. Specific criteria must be met to determine the level of service provided.

The proposed model requires less documentation to support the billed level. A proposed default payment of $135 for new and $93 for established patients will help simplify the process. This proposal raises the reimbursement for levels two and three but lowers it for both four and five. To offset some of these losses and allow for a better picture of the visit itself, add-on payments for services, such as prolonged visit and additional resource use are also proposed.

Currently, providers can use the 1995 and 1997 guidelines for E / M documentation, and can decide which one is more beneficial to them in leveling their visit. The proposed rule allows for the use of time or medical decision-making as the basis for choosing the level of the encounter. Using a minimum documentation standard allows for more face-to-face time as it would reduce the amount of time and effort required for documentation of items not directly relevant to the care of the patient at that time. The documentation standard for a level two E / M would be considered appropriate for any level.

CMS is encouraging the application of new technology, including synchronous and asynchronous video-conferencing and remote patient monitoring to more efficiently bring care to Medicare beneficiaries. In line with this, communication technology increases access. Rural Health Clinics and Federally Qualified Health centers would be paid for remote virtual evaluations even when there is no associated billable visit.

Other new technology-based services are also being proposed. For example, a phone call or other tech-based communication would be billable if used to decide if a service or office visit is needed. Additionally, there may be a separate payment for a physician reviewing images submitted by the patient.

Again, this is a proposed CMS rule for calendar year 2019 and will be an important one for the health care community to follow closely. Questions can be directed to your Quartz representative.