CMS’s Proposed E&M Coding Changes – and the Rest of the Story

The proposed documentation changes will require retraining an entire industry.

EDITOR’S NOTE: The public comment period for the 2019 proposed MPFS closes Monday, Sept. 10, 2018.

The 2019 proposed Medicare Physician Fee Schedule has clearly articulated the Centers for Medicare & Medicaid (CMS) goal of “patients over paperwork.” I think almost everyone agrees with that goal. Most physicians applaud any improvement in lessening the documentation burden and “note bloat.”

The concern with the proposed rule is that in many ways, increased burden for physicians and their agents and representatives will ensue. That burden will almost certainly come with increased costs, lower reimbursement, and even more efficiency disruptions. While most do not expect a final decision and implementation in 2019, CMS has provided insight into its vision for future payment policies. Rather than looking solely at the proposed decreased documentation burden, let’s review the devil in the details.

The proposed rule and request for input provides the possibility of multiple ways to document an evaluation and management (E&M) service. Currently, physicians can use the 1995 or 1997 E&M documentation guidelines, and that option would continue under the new proposal. Proposed time-based options include choosing the current time-based criterion or average visit time (or preponderance of time). Also up for consideration is documentation based solely on medical necessity; however that would be defined. There would be the potential for add-on Healthcare Common Procedure Coding System (HCPCS) codes for specific specialties and complexity of visits.

The devils hidden in these proposals are myriad.

First and foremost, will any commercial insurance plan accept the potential documentation changes, or will physicians need to document by payor and plan? Which set of E&M documentation guidelines would apply to crossover claims? Are physicians really going to be expected to research primary and secondary insurance before documenting their services?

Many, if not most, physician E&M services are coded by professional coders using standard guidelines. Likewise, auditors use standard guidelines in reviewing E&M claims. Under the various proposed documentation options, a standard methodology for determining the accurate E&M level of service must be established.

Will physicians be permitted to use any method on any visit, or will they be limited to choosing the one that works best for them? What criteria will be implemented to ensure that Medicare beneficiaries will have the same level of service assigned for the same problem by different physicians or coders? Will physicians, coders, and auditors use the same set of documentation guidelines for the same visit? Will the CMS Medicare contractors be permitted to have idiosyncratic guidelines, and audit tools as they do now?

Physicians have loudly and consistently bemoaned “note bloat,” medical records of enormous length with unnecessary redundancies that make ascertaining meaningful information difficult. The fact is that these same redundancies are the direct result of the outdated E&M guidelines that CMS based on a counted methodology that has little relevance to medical necessity and necessary documentation. However, we need to recognize that “note bloat” was rarely a problem before electronic health records (EHRs). Physicians typically did not write 15-plus pages for an office visit, no matter the complexity. With EHR implementation came automated templates that included the counted methodology, chart by exception (which does not always work), carry-forward information, and one-click autofill. These programmatic options were intended to reduce documentation burdens and allow physicians to be more efficient. Unfortunately, the exact opposite has happened. Rather than simply reviewing past information, test results, and other providers’ notes, the entire “chart” may be carried forward for each visit. These technologies also made it very easy to include incorrect and outdated information, making it increasingly difficult for physicians to sort through what is accurate and what matters in their notes and in the notes of other physicians.

The cost to implement and customize current EHRs is very high. Many have built-in documentation prompts, E&M code assignment or recommendations based on documentation, quality payment metrics, drug formularies, risk checks, and other clinical data separate from E&M services.

CMS must recognize that the proposed documentation changes will require retooling, reprogramming, and retraining an entire industry. This issue will be even more complex and expensive if commercial plans do not adopt the proposed CMS documentation guidelines. In addition, the billing and revenue systems, data analytics, and financial projections will require reprogramming. CMS and physicians need to understand that the proposed E&M documentation changes will not occur in isolation, even if successfully decreasing documentation burden.

As part of the proposed overhaul, CMS also proposes collapsing the five new patient and five established patient office visits to two levels for each category of visit services. Although this may be of some benefit to certain specialties or practices that tend to see very low-complexity patients, it will negatively impact specialties that see more difficult and complex patients. This is also very true for those primary care practices that have large Medicare populations. Presumably, this will also lessen the documentation and audit burden, but at what cost to the practice? As discussed above, the commercial plans and payors may or may not follow this proposed rule, if implemented. An add-on HCPCS code used for specific Medicare visits would not resolve the issues addressed. The potential loss of revenue would be unsustainable for some practices and physicians.

Lastly, the proposed E&M changes include applying the multiple procedure payment reduction (MPPR) to all office visits when a minor procedure is also performed. The reduction would be 50 percent of the lower-cost service when a minor procedure is performed in conjunction with an E&M with modifier 25 (for a significant, separately identifiable service). I believe the CMS rationale is flawed in the assumption that there is always duplication of substantial portions of the two services.

Although the CMS carrot of decreased documentation burden is tempting and much-needed, the stick of unintended consequences is very real. I encourage physicians and their representatives to thoughtfully consider the devil in the details of these proposed E&M payment policies. Participation following future CMS requests for information and dialogue should be a high priority.

If commercial plans or other payors base their allowables on a percentage of Medicare, additional losses will occur for higher-complexity visits. Detailed data analysis is necessary to determine how each of these proposed changes, if implemented, would affect your practice, your EHR, your staff, your cash flow, and your administrative burden.

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