Changes on the horizon for evaluation and management documentation and reimbursement

CMS finalizes E/M documentation and reimbursement changes

On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) published its 2019 Physician Fee Schedule (PFS) with updated payment policies, rates and quality provisions that alter documentation requirements and reimbursement for evaluation and management (E/M) services.

In keeping with CMS' stated desire to reduce administrative burdens and improve the accuracy of payments for E/M visits, the PFS final rule implements several changes to documentation polices for the immediate future (CYs 2019 and 2020), as well as documentation, coding and payment changes in the years ahead (CY 2021). Specifically, CMS finalized for CY 2019:  

  • Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit

  • For established patient visits, practitioners may document what has changed since the last visit-or pertinent items that have not changed-when relevant information is already in the medical record, and need not re-record the defined list of required elements if practitioners review the prior information and no update is warranted

  • For E/M visits, practitioners need not re-enter the patient's chief complaint and history that has already been entered by ancillary staff or the beneficiary. Practitioners may simply indicate the medical record has been reviewed and verified.

CMS will retain the Current Procedural Terminology (CPT®) E/M codes but will establish one payment rate for CPT codes 99202 through 99205 (new patient) and another payment rate for CPT codes 99212 through 99215 (established patient). CMS says practitioners will only need to meet documentation requirements currently associated with a level 2 visit for history, exam and/or medical decision-making. Practitioners can continue to choose and report the level of E/M visit they believe to be appropriate under the CPT coding structure. It is important to note that CMS did not make any changes to the ophthalmological examination code series (92xxx codes). 

Below is the finalized payment schedule for E/M services:

Proposed Schedule Table
When CMS unveiled these significant changes to E/M service documentation and payment, the AOA met with high-level officials at the Department of Health and Human Services to discuss how the proposal would impact optometry. The AOA communicated to CMS that while the AOA appreciates the agency examining physician burden related to documentation, it was concerned that an implementation date for new changes in 2019 was too soon for the physician community to fully understand and implement these changes. Additional time was necessary to ensure that the new reimbursement structure is fully addressed, appropriate and fair. The AOA asked the agency to delay any final changes to reimbursement for these services.

In the final rule, CMS noted that practitioners should continue using either 1995 or 1997 versions of E/M guidelines while it begins discussions on a refined coding and payment structure for E/M visits for 2021.

Overall, it is critical that practitioners document medical record information consistent with the level of care furnished for clinical, legal, operational or other purposes. Additionally, it's important to note that these changes are only for the Medicare program. The AOA will keep members apprised of any changes.

Click here
to review the 2019 Medicare PFS, and click here to read more about the wins AOA gained for optometry in the most recent PFS.

November 28, 2018

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