Evaluation and management (E/M) coding is complex and many providers outsource medical billing and coding to report services and maximize revenue. To add to physicians’ woes, E/M documentation is a time-consuming process that takes away precious time from patient care. CMS has suggested changes to simplify documentation requirements for office/outpatient E/M visits (CPT codes 99201 through 99215) in its proposed 2019 Medicare physician fee schedule (PFS).
- Reduced documentation requirements for office, other outpatient, and home E/M visits: The proposed rule seeks to allow physicians to choose from two options:
- Physicians can use either the 1995 or 1997 Documentation Guidelines for E&M services. The proposed Rule seeks to minimize documentation requirements by only requiring practitioners to meet the documentation requirements for history, physical exam, and MDM that currently are associated with a level 2 office/outpatient E/M visit (except when using time to document the service) and to document the medical necessity of the visit.
- Practitioners could use MDM or time to document an E&M visit, in lieu of the documentation guidelines.
- Using MDM: Under the proposal for using just MDM to establish the level of an E/M visit, Medicare’s requirement would be limited to documentation associated with a current level 2 CPT visit code and that needed to support the medical necessity of the visit. The proposed Rule allows practitioners to use MDM in its current form to document the E/M visit.
- Using Time: Providers can use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether they spend most of the visit providing counseling or care coordination. The physician has to document the medical necessity of the visit and show the total amount of face-to-face time spent with the patient.
CMS has made three suggestions regarding the total time required for payment of the new single rate for E/M visits levels 2 through 5:
- Using the typical times for E/M visits in the physician time files used to set PFS rates (38 min for a new patient, and 31 min for an established patient)
- Applying to CPT codebook provision that, for timed services, a unit of time is attained when the midpoint is passed
- Using the American Medical Association’s (AMA’s) CPT code requirement to document time spent face to face by the physician with the patient
The main goal of these proposed changes is to reduce practitioners’ documentation burden and provide them with more time for their patients. According to a Lexicology report, “the proposals would save clinicians approximately 1.6 minutes of time per office/outpatient E/M visit, which for a full-time practitioner with a payer mix that is 40% Medicare (60% other payers), the practitioner would have approximately 51 additional hours to spend with patients every year”. However, an ICD-10 Monitor report notes that while practitioners might benefit from the reduced documentation requirements for relatively healthier patients, those who see patients with multiple medical problems and complex conditions that require more time and effort would experience some loss in revenue.
Medical billing and coding correctly for E/M payment can be challenging. A study by the Office of the Inspector General (OIG) found that 42 percent of claims E/M services in 2010 were inaccurately coded, which included both upcoding and downcoding, and 19 percent lacked documentation. Outsourced medical billing and coding is a reliable option to ensure accurate reporting of E/M claims using valid E/M codes, add-on codes, and modifiers. Providers, on their part, are responsible for accurately, completely, and legibly documenting the services performed.
The proposed Rule’s policy changes would become effective for Part B services beginning January 1, 2019. CMS will accept comments until September 10, 2018.