CMS Appears Willing to Change Method of Selecting E&M Code

CMS engages in lively discussion about the proposed 2019 MPFS.

The Centers for Medicare & Medicaid Services (CMS) was asked yesterday by a listener if the agency considers their proposal to change the method of selecting the E&M code by using time, medical decision-making, or the current system and the change to a blended payment rate for these visits to be inextricably linked or whether they would adopt one and not the other.

The agency responded that they are open to unlinking them and would welcome comments.

CMS held the listening session on Wednesday during a call that was billed as the Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session.

In previous listening sessions, CMS listened but did not comment. This call was a welcome change from that. The call began with very thoughtful introductory comments from Seema Verma, the CMS administrator, who emphasized that the proposed changes were in response to the administration’s ongoing efforts to prioritize patients over paperwork and to adapt to the changing ways that medical care is being provided.

The CMS staff gave some brief introductory comments on the three topics; Documentation Requirements and Payment for Evaluation and Management (E&M) Visits, Advancing Virtual Care, and Quality Payment Program. After comments, CMS opened the lines for callers to ask questions. The staff did note several times throughout the call that any comments made should also be submitted in writing if the caller wanted them formally considered.

The questions and comments were remarkably in depth, raising many concerns that had not been addressed in other commentary. And surprisingly, although a few callers noted the adverse financial impact of the proposal on physician, not one caller was angry or belligerent. Although most callers did not provide their credentials, it seemed that the majority were in administrative positions as opposed to practitioners.

A few questions and comments brought up information that was not evident from the proposed rule itself. First, it was noted that the proposed primary care add-on code GPC1X can be used by any specialty if the visit is a primary care service. The description in the rule mentions OB/GYN and cardiology as two specialties that can potentially use this code but noted that these were provided solely as examples.

The proposed add-on code for prolonged E&M service was also discussed. As proposed, the code GPRO1 will be defined by “additional 30 minutes” but to use the code, the visit must only exceed the typical time for the chosen E&M code by 16 minutes. This now gets a bit complex because CMS has not definitively established what typical times are being proposed for the E&M visit. If CMS adopts the blended payment rate proposal, physicians will only need to document to a 99212 to get the payment. In 2018, a 99212 has a typical time of 10 minutes. In that scenario, a 26-minute visit would allow the physician to bill a 99212 and GPR01 (along with GPC1X primary car add on code in most circumstances.

But CMS has also proposed to set the typical time for the blended visit rate at 31 minutes. If they adopt that typical time, then a visit would need to be 47 minutes to be billed with 99212 and GPR01, a time which is reached much less frequently than 26 minutes. CMS did ask for comments on which typical times to adopt for use. Suggesting to CMS in writing that they continue with the current times seems wise.

I also asked about discussions with other payers about their proposal and they stated that they have not talked to other payers, also noting for another caller that the proposal does not apply to Medicare Advantage plans.

Sandy Dixon, the director or quality and compliance for Metrolina Nephrology Associates in Charlotte, North Carolina, a large group practice that cares for over 20,000 patients, most of whom are covered by Medicare, noted that their internal calculations indicate a nearly 10% reduction in revenue and questioned CMS’s calculations. She noted that “we are still catching up from the 2010 elimination of consult codes” and that her physicians see complex patients every day and “do not have an additional 30 minutes to spend with each patient to be able to use the prolonged service code.”

Ms. Dixon also wisely noted that, in her opinion, these proposals are far from less burdensome from an administrative viewpoint. One would be hard to argue that point since as noted above these changes apply only to Medicare and therefore doctors would need to document differently depending on the payer. A caller from a single-physician cardiology practice (they still exist?) also noted the confusion that will result when a specialist sees an outpatient or observation patient in the hospital and must use the office visit codes. That caller also proposed an add-on code for such patients to account for the inherent increased complexity with a patient who is hospitalized compared to a patient seen in the office. This is an idea that I wish I had thought of!

Jim Blakeman, listed on LinkedIn as executive vice president of Emergency Groups’ Office, brought up the issue that seems to be a recurrent theme in written comments submitted so far to CMS. He noted that because of the payment reduction, it is felt that many physicians will refer their patients with complex problems to the emergency department for evaluation rather than attempting to manage them in the office, thereby raising overall costs to Medicare. The CMS representative noted that it is their opinion that the primary visit code, along with the prolonged service code, and the primary care add-on code will properly compensate physicians for their time and effort.

Barbara Olsen, from Baltimore, asked a question that many in the audit community have been asking- how will these visits be audited? The response was that she should submit a comment. The question of audits raises many questions, such as- if CMS lets physicians choose how they pick an E&M code, how will an auditor know which method was used? If a physician has a 50-minute visit, codes the visit a 99212 and uses the prolonged service code, can the auditor review the claim and deny it by stating that the documentation supports a 99214 and therefore the typical time threshold of 40 minutes for 99214 should have been used? What guidelines will be used for medical decision making? Wil start and stop times be needed or will total time be acceptable?

CMS also spent a bit of time on the proposed codes for “virtual check in visits.” They noted that these visits would allow physicians to be paid for non-face-to-face visits using technology to communicate with the patient who may not require an office visit or is unable to arrange transportation. They were asked about what means of communication would be eligible and answered that they purposely chose to avoid being specific in describing the means of communication because of the rapid change in technology and methods of communication and asked for comments.

Hopefully, CMS will be more specific in the final rule, along with addressing such issues as what type of documentation will be required if the visit is a video or telephone communication, whether texting will be acceptable, and whether patient consent is required for the visit to be billed.

The CMS representative noted that a recording of the call along with a transcript will be posted within a week at: and comments must be submitted by September 10th at CMS has a herculean task ahead of them; as of today, there are 2,768 comments.


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Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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