Medical Management Associates, Inc. - Healthcare Consulting Logo

3330 Cumberland Boulevard • Suite 200 • Atlanta, GA 30339
Phone: 770-951-8427 • Fax: 770-951-2157

Proposed Change to 2019 Medicare Payment Rates, Coding and Documentation of E/M Service

John M. Bennett, CPMA, Senior Associate
John M. Bennett, CPMA
Senior Associate

You may have heard some rumblings about Medicare's proposed changes to reimbursement of Evaluation and Management (E/M) services for 2019. These proposed E/M changes were released by the Centers for Medicare and Medicaid Services (CMS) in July, along with many other Medicare Physician Fee Schedule changes proposed for CY 2019. Some of the changes are likely to decrease reimbursement for E/M services, while others may increase reimbursement and/or counter-balance lower reimbursement with simplified coding and documentation of E/M services. Essentially, the proposed rule calls for what I consider to be nine (9) major changes related to E/M services, which are summarized below.

  1. Medicare would have a single payment rate for levels 2-5 for new and established patient office visits. Providers would continue to report on the claim whatever level of visit they furnished using CPT codes 99201-99215. However, CPT codes 99202-99205 would have a Medicare fee schedule of $135 and CPT codes 99212-99215, a fee schedule of $93. That may sound great for those of you frequently reporting lower-level office visits and not-so-great if you are on the other end of the coding curve.
  2. The proposed rule contains efforts to simplify coding and documentation of E/M services. These changes could drastically streamline the provider's documentation of the patient encounter, which is consistent with the CMS "Patients over Paperwork" initiative.
    1. Providers would be able to select the level of E/M code based on one of the following three criteria: current 1995/1997 documentation guidelines (history, exam, medical decision making); time (when counseling dominates at least 50%); or medical decision making. Currently, the criteria for E/M code selection are based on either current 1995/1997 documentation guidelines or time.
    2. Providers would only need to meet minimum documentation standards currently associated with a level 2 history, exam and/or medical decision making (except when using time) to support the single E/M payment for office visit codes (levels 2-5).
    3. Also, CMS has proposed to further simplify the documentation for established visits by allowing practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information.
    4. Further, CMS proposes that for both new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the patient's chief complaint and history that are already entered by ancillary staff of the beneficiary. Instead, the provider could indicate in the record that they reviewed and verified this information.
  3. Now some bad news. Medicare would apply a 50% multiple procedure payment reduction when an E/M code is reported on the same day as a procedure with a global period. The payment reduction would apply to the least expensive service, which will often be the E/M code. Currently, Medicare does not reduce payment when an E/M code is reported with modifier -25 on the same day as a procedure with a global period. Supposedly, payment reductions are reallocated to payments for new E/M G-codes below (the theory is that payments remain budget neutral). Of course, providers who commonly report E/M with minor surgical procedures will see a bigger impact.
  4. New add-on code (GPC1X) for primary care services could be reported with each stand-alone office visit for established patients. The Medicare fee schedule would be approximately $5. CMS expects to see the add-on code billed with every stand-alone established patient office visit. The add-on code is not reported with new patient office visit code or E/M visit reported on the same day as a procedure with a global period (i.e., minor surgical procedure). The purpose of the add-on code is to account for higher-level/complex office visits associated with primary care. Primary care is not defined in the proposed rule (CMS is seeking comments).
  5. The proposed rule also includes a new add-on code (GCG0X) for specialty professional care services to be reported with each stand-alone office visit for established patients. The Medicare fee schedule would be approximately $12-14. The add-on code is not reported with new patient office visit code or E/M visit reported on the same day as a procedure with a global period. The purpose for this is to account for higher-level/complex office visits associated with specialties that frequently report office E/M. CMS expects to see the add-on code billed with every stand-alone established patient office visit reported by the identified specialists:
    1. Endocrinology
    2. Rheumatology
    3. Hematology/Oncology
    4. Urology
    5. Neurology
    6. OB/GYN
    7. Allergy/Immunology
    8. Otolaryngology
    9. Cardiology
    10. Interventional Pain Management
  6. New codes (GPD0X and GPD1X) for podiatric E/M visits would be reported instead of office E/M codes (99201-99205 and 99211-99215). The new codes define podiatry services, medical exam and evaluation with initiation of diagnostic and treatment program. GPD0X would be used for new patients and have an estimated fee schedule of $102. GPD1X would be used for established patients and have a fee schedule of approximately $67.
  7. New code (GPRO1) for prolonged E/M services would have a fee schedule rate of $67. The new add-on code would be reported in addition to E/M code to describe prolonged E/M in the office or other outpatient setting requiring direct patient contact beyond the usual time of service: 30 minutes. The existing CPT code 99354 describes 60 minutes of prolonged service, which will remain unchanged and available for the provider to bill should the prolonged service meet the threshold. Of course, time would need to be documented in the record since these are time-based codes.
  8. New code (GRAS1) with a $13 fee schedule rate would be billed for remote services when a physician uses pre-recorded video and/or images submitted by a patient to evaluate a patient's condition. Code GRAS1 is defined as "Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward) including interpretation with verbal follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment."
  9. New code (GVCI1) with a $15 fee schedule rate would be used for a "virtual check-in" service. This service would be billable when a physician or other qualified health care professional has a brief non-face-to-face check-in with a patient via communication technology to assess whether the patient's condition necessitates an office visit. Code GVCI1 is defined as a "Brief communication technology based service, e.g., virtual check-in, by physician or other qualified healthcare professional who may report evaluation management services provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to and E/M service were procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion." The code description and value are based on CPT 99411 (telephone evaluation and management service), which is currently not separately payable under the Medicare fee schedule. CMS points out in the proposed rule that GVCI1 would include telephone calls and other communication modalities.

Remember that the proposed rule is open for comment until September 10, 2018 and is subject to change (and probably will). Based on my experience, CMS will likely publish the final rule in November. With that said, if CMS goes forward with the flat payments rates for E/M, I expect the final rule will include a one-year transition period to allow physicians and billing process stakeholders to get ready for the change. Regardless, once the 2019 fee schedule is finalized, managers will need to ensure their providers and support staff are adequately trained on the changes.

If you have questions or would like assistance with these reimbursement changes, please contact John Bennett at 770-951-8427, ext. 257 or jmb@medicalmanagement.com.

Learn How MMA Can Help YouGET STARTED770-951-8427