Overview of the 2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule: Evaluation and Management Codes

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Practices should consider making comments on the MPFS Proposed Rule as it may impact your practice significantly. The proposed rule is available under the PDF link here. Comments are due by Monday, September 10 at 5:00 pm ET and can be made here.

Some of the biggest changes to the MPFS Proposed Rule deal with Evaluation and Management Codes. The last big change to Evaluation and Management codes occurred in January 2010 when CMS removed consult codes from the Medicare Claims Processing Manual. 

CMS is currently focused on its initiative “Patients over Paperwork” that launched in October 2017. CMS believes these changes would increase the amount of time doctors and other clinicians spend with their patients by reducing the amount of Medicare paperwork. 

CMS is proposing a new reimbursement methodology for new patient evaluation and management codes level 2-5 (99202-99205) and established patient evaluation and management codes level 2-5 (99212-99215). Beginning in 2019 these services would receive a single flat rate. Their rationale is to eliminate the need to audit against visit levels and reduce the documentation burden. This is not expected to change the documentation requirements for private payers, so back offices will be dealing with two sets of requirements, depending on insurer.

This change would standardize the payments for all new and established office visits. What providers could be looking at is a proposed new patient Level 2 – Level 5 code payment of $135 (national average for 2019) versus the range of current code payments from $76 - $211 (national average).  Established patients will follow a similar format. (Note: This information was taken from Tables 19 and 20 from the CMS 2019 PFS Proposed Rule).

CMS believes that when a separately identifiable visit is furnished in conjunction with a 0-day global procedure, there are certain duplicative resource costs that are not accounted for by current coding and payment. They are proposing payment be reduced by 50% for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier -25 (page 354 of the Proposed Rule).

In tandem with the reimbursement change CMS is proposing to allow practitioners to choose how they would like to document office/outpatient E/M visits instead of applying the current 1995 or 1997 E/M documentation guidelines. Proposed changes include:

  • Allow providers to use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit.
  • Allow providers to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information.
  • Allow providers to review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it. 

CMS noted that the distribution of E/M visits is not uniform across medical specialties and proposed several new G codes as E/M add on services. These include G codes for primary care services, specialty professionals, podiatrists and prolonged services. Specialists in areas such as endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care performing higher level, more complex visits would use GCG0X. But again this could cause confusion for coders based on the documentation requirements for different commercial payers.

This information was taken from an InfoDive webinar on July 25, 2018 on the 2019 MPFS Proposed Rule.