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).

Documentation
  • 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
  • Less documentation requirements specifically for home visits and same-day visits: Medicare beneficiaries don’t have to be confined to the home to be eligible for home visits as long as the medical record includes documentation of the medical necessity of a home visit as opposed to an office or outpatient visit. CMS also proposes to eliminate the Medicare Claims Processing Manual’s prohibition on billing same-day visits by practitioners of the same group practice and specialty unless there is documentation that the visits were for unrelated problems.
  • Single rate for E/M levels 2-5: The proposed Rule seeks to simplify E/M billing and minimize documentation requirements by reimbursing a single rate for level 2-5 E/M visits for new patients and a different single rate for established patients. These new single payment rates would apply regardless of the option chosen to document the visit. CMS considers that this will reduce the amount of work it takes to document the correct visit level and eliminate the need to audit against the visit levels. Physicians can continue to bill the CPT code for whichever level of E/M service they furnished.
  • New add-on codes to better capture E/M visits for more complex patients: Certain specialties can bill office visits for more complex patients using an add-on G code with the E&M primary code to adjust payment for additional costs beyond the typical resources used in levels 2-5. Specialties approved for reporting a complexity code include: endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, and interventional pain-centered care.
  • Multiple procedure reduction policy for procedures and E&M visits on the same date: CMS has proposed a multiple procedure payment reduction (MPPR) policy that would apply when E/M visits are provided in conjunction with other procedures. When physicians an E/M service and a procedure are reported on the same date, CMS proposes a 50 percent multiple procedure payment reduction for the lower paid of the two services by the same physician or a physician in the same group practice. Modifier 25 would be appended to the E&M service.
  • Relaxing the requirement for teaching physicians to personally document their participation in an E/M procedure in the medical record: Currently, providers under the supervision of teaching physicians can make notes in the medical record, and the teaching provider must personally document their involvement. As stakeholders consider this process duplicative and burdensome, CMS proposes the medical record must only document that the teaching physician was present at the time the service was furnished.

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.