September 5, 2018

Why 170 medical groups aren't fully on board with the 2019 Physician Fee Schedule—yet

Daily Briefing

    The American Medical Association (AMA) and 170 other medical groups in a letter last week signaled their support for a proposed rule that aims to reduce health care providers' administrative burdens, but they raised concerns about proposed changes to payment rates for certain office visit services.

    Download our one-page cheat sheet on Medicare Physician Fee Schedule (MPFS)

    Proposed rule details

    CMS in the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2019 proposed overhauling Medicare billing standards that have been in place since 1995. Currently, most physicians bill Medicare using evaluation and management visit (E/M) codes, a generic set of codes that set levels of complexity and site of care. Under the proposed changes, CMS would collapse the payment rates for various levels of evaluation and management codes.

    To support this change, CMS proposed allowing clinicians to use their own medical decision-making or the time spent with a patient to determine the level of a patient's care needs, instead of relying on the evaluation and management codes. CMS also proposed eliminating the requirement that providers justify the medical necessity of a home visit over an office visit. The agency also proposed eliminating requirements for physicians to re-document information added to a patient's records either by practice staff or the patient or during a previous visit. The agency also said it is considering eliminating a policy that prevents Medicare from reimbursing providers for same-day visits with multiple clinicians in the same specialty within a group practice.

    Groups support efforts to reduce administrative burdens

    AMA and other medical groups in a letter sent to CMS Administrator Seema Verma wrote that they "welcome and strongly support" the agency's efforts to reduce administrative burdens for providers.

    The groups wrote, "Physicians and other health care professionals are extremely frustrated … with pages and pages of redundant information that makes it difficult to quickly find important information about the patient's present illness or most recent test results." As such, the groups urged CMS to immediately adopt its proposal to eliminate requirements for physicians to re-document information and justify the use of a home visit over an office visit, writing that those proposals "would go a long way toward alleviating" the physicians' difficulties maintaining and navigating patient records.

    The groups wrote, "Implementation of these policies will streamline documentation requirements, reduce note bloat, improve workflow, and contribute to a better environment for health care professionals and their Medicare patients."

    Groups oppose proposal to collapse payment rates

    However, the groups wrote that they "oppose the implementation of" CMS' proposal to collapse certain payment rates for office visits because the proposal could hurt physicians and other health care professionals in specialties that treat the sickest patients, as well as those who provide comprehensive primary care, ultimately jeopardizing patients' access to care." The groups urged CMS not to move forward with the proposal, arguing that it would have a "significant impact on certain services, such as chemotherapy administration, that may be an unintended consequence of altering the current practice expense methodology."

    Instead, the groups recommended that CMS create a workgroup of physicians and other health care providers with expertise in defining and valuing codes to help address "the issues surrounding the appropriate coding, payment, and documentation requirements for different levels" of evaluation and management. AMA and the others groups said the workgroup could analyze evaluation and management coding as well as payment issues "to arrive at concrete solutions that can be provided to CMS in time for implementation in the 2020 Medicare Physician Fee Schedule."

    Separately, a coalition of 120 provider and patient advocacy groups led by the American College of Rheumatology in a letter also sent to Verma signaled their opposition to collapsing the billing codes, arguing that the move would result in payment cuts for certain evaluation and management visits.

    The groups wrote that the move essentially would penalize physicians who treat patients with chronic conditions. They urged "CMS to reconsider this proposal to cut and consolidate evaluation and management services, which would severely reduce Medicare patients' access to care by cutting payments for office visits, adversely affect the care and treatment of patients with complex conditions, and potentially exacerbate physician workforce shortages" (Ellison, Becker's Hospital CFO Report, 8/28; Jones Sanborn, Healthcare Finance News, 8/28; Japsen, Forbes, 8/28).


    Still digging through all the new Medicare rules? Here's what you need to know.

    In recent months, CMS has released proposed and final rules for some of Medicare's most important, and often confusing, programs covering inpatient payments, outpatient payments, and more. With all of the complex changes, it can be difficult to remember just what each rule covers and how its calculations work.

    Download our one-page cheat sheets for a quick overview of each rule's scope.

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