Final 2019 & Proposed 2021 CMS Physician Fee Schedule Changes

Many have heard the conversations and read articles surrounding efforts to simplify E/M billing, coding, and documentation. Most of the larger proposed changes were officially postponed to 2021 which will give stakeholders time to influence the final policy. This announcement on November 1, 2018 coincided with the release of the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) final rule.

Providers (and coders alike) have long complained about the burdensome process of meeting certain documentation requirements when seeing patients. Providers are not able to just write down what is wrong and what they did, but they must also jump through many hoops to show they completed a certain number of review of systems, examined a certain number of body systems and or organs, etc. in order to support levels of E/M being billed.

In a world of pressure to see more patients each day, to fully document everything on every visit, and to still keep track of medications being taken, historical medical elements to consider, and possible interactions of medications and comorbidities while treating the simplest of medical problems has caused documentation burn out.

The original proposal was to collapse the entire 5 tier E/M system, however the newest version of this is to collapse the first 4 levels of service and to preserve the level 5 visits to “better account for the care and needs of complex patients.”

Because of a flooding of negative comments and concerns, CMS decided against other controversial items in the original proposal, to include reduction of payment for E/M visits provided on the same day as a procedure, a separate E/M coding and payment system for podiatric E/M visits, and a standardized allocation of practice-expense relative value units (RVU) for certain codes.

Final Rule Effective Jan 1, 2019:

Between 2019 and 2020, providers may still use either the 1995 or 1997 guidelines for reporting E/M services.

Beginning January 1, 2019, providers may focus their documentation on what has changed since the last visit with an ESTABLISHED patient and will no longer be required to re-document any of the required E/M elements, provided that they document evidence that the former information was reviewed and updated as needed.

For NEW and ESTABLISHED patients, providers will officially not need to re-document the chief complaint or HPI (History of Present Illness) if it has already been noted by other medical staff (nurses, medical assistants, etc.) or by the patient themselves. The treating provider must still document they reviewed this information.

Teaching physicians no longer need to re-document in medical records that have already been documented by residents or other medical team members.

Providers also no longer are required to document the medical necessity of a home visit in lieu of an office visit.

The Plan [Effective Jan 1, 2021]:

NEW patient visits for office and outpatient E/M 99202, 99203, and 99204 will all reimburse at a single payment rate. The expected dollar value will be between what would have been for payment for codes 99203 and 99204 in 2021.

ESTABLISHED patient visits for office and outpatient E/M 99212, 99213, and 99214 will all reimburse at a single payment rate. The expected dollar value will be between what would have been for payment for codes 99213 and 99214 in 2021.

Providers will still be able to select the level of NEW or ESTABLISHED patients E/M code levels 2 through 5 based solely on

  1. Medical Decision Making, or
  2. Time, or
  3. The CMS 1995/ 1997 documentation guidelines for E/M services.

When the visit falls between levels 2-4, providers will only need to document enough information to meet the requirements of a level 2 visit.

Effective January 1, 2021, there is a plan to offer add-on codes for additional resources needed for primary care and other non-procedure related specialized care. The add on codes will not be restricted by any specialty and they will only be allowed for office and outpatient E/M services levels 2-4.

There will also be an “extended visit” add-on code that will only be allowed to use with office and outpeitnet E/M services level 2-4. The purpose of the extended visit add-on is to account for additional resources needed when providers need to spend more time with a patient for various reasons.

More Information:

According to CMS officials, the Quality Payment Program is continuing to use a framework established by the “Patients Over Paperwork” initiative, to implement meaningful measures, promote interoperability, support small and rural practices, reduce clinical burden, and improve patient outcomes.

The changes also establish CMS payment when beneficiaries connect with their doctor virtually using telemedicine to determine whether they need an in-person visit. There is an added focus on measures that most significantly impact health outcomes according to CMS.

The final 2019 Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) released helps to modernize Medicare payment policies to promote access to virtual care which is seen as an effort to save Medicare patients time and money while improving their access to high quality services, regardless of where they live.

CMS projects these changes will save clinicians $87 million in reduced administrative costs in 2019 and $843 million over the next 10 years. The changes are also expected to result in 21 million hours saved for physicians over 10 years beginning in 2021 per CMS.

Reimbursements for Virtual Care:

CMS officials have said that provisions in the CY 2019 PFS would support access to care using telecommunications technology. Under the final rule, Medicare will pay providers for new communication technology-based services, such as brief check-ins between patients and practitioners, and pay separately for evaluation of remote pre-recorded images and/or video. CMS is also expanding the list of Medicare-covered telehealth services.

Helpful Links:

Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019

Federal Register

Note: CPT® is a Registered Trademark of the American Medical Association

Brian Boyce, BSHS, CPC, CPC-I, CRC, CTPRP is an AAPC-approved PMCC medical coding instructor, and ICD-10-CM trainer and the author of the AAPC CRC® curriculum. He has specialized in risk adjustment from the very beginnings of these models being utilized and has assisted large and small clients nationally. He has special interest in ethics, patient safety, disease management, and management and leadership of people. Brian is a veteran of Desert Storm, where he served on active duty with the US Air Force with a job specialty of Aeromedical Evacuation. He went into physician practice management and medical coding after an honorable discharge. He is the CEO of ionHealthcare® LLC, a company that specializes in healthcare consulting, risk adjustment coding, management & support services. For additional inquiries contact ionHealthcare® at info@ionHealthcare.com.