After provider uproar, CMS steps back from major E/M revamp

By | November 5, 2018

Dive Brief:

  • CMS has finalized the Physician Fee Schedule for 2019, pushing back a controversial flattening of E/M codes to 2021 after a backlash from providers and physicians. The rule also cuts some E/M documentation requirements and removes duplicative notation requirements.
  • New payments for a number of telehealth services, including prolonged preventative services, virtual check-ins and evaluation of videos and photos submitted by established patients are also part of the rule. In following the Trump administration’s efforts to lower the cost of drugs, it halves the add-on percentage CMS pays when acquiring new drugs under Medicare Part B, from 6% to 3%. 
  • Time-sensitive rules were also finalized for Accountable Care Organizations under the Medicare Shared Savings Program. CMS is now allowing voluntary six-month extensions for ACOs whose agreements end in December and providing relief for ACOs impacted by recent natural disasters. The agency has also cut eight MSSP quality measures. 

Dive Insight:

CMS has listened to widespread industry feedback on its E/M proposals by streamlining some evaluation and management requirements while holding off on controversial proposal to flatten E/M codes in 2019. The agency pushed that plan back to 2021 in order to “work with stakeholders and get their input,” CMS Administrator Seema Verma said on a call with reporters Nov. 1.

In 2021, CMS plans to begin paying a single rate for E/M visit levels 2 through 4 for both established and new patients, while maintaining visit level 5, which account for the complex needs of patients with chronic or multiple conditions. The agency will also allow for more flexibility in how visits are documented and implement a number of add-on codes to accommodate for extended visits and “additional resources” used during a visit. 

“This has been a thorny issue for years,” Verma said. 

Hospital groups and patient advocates agree, and none were happy with the proposed changes in July. Verma said CMS received roughly 15,000 comments on its E/M proposals. The overwhelming majority of hospital and provider groups opposed the proposal, many banding together under the auspice of the American Medical Association to request CMS push the rule back and instead convene a stakeholder group to devise an alternative solution. 

The image below reflects new E/M payment rates for 2019. 

Source: CMS

Despite decades-long disputes about E/M policy, many groups, including the American Medical Group Association, felt CMS’ proposal to flatten codes was a change they hadn’t asked for. 

“AMGA members were very concerned that CMS was moving too aggressively in its plan to streamline the payment and coding for E/M office visits, particularly those providers who treat a large number of complex patients,” AMGA President Jerry Penso said in a statement. “Maintaining the code for the most complex patient visits somewhat alleviates that concern.”

AMA expressed gratitude that the agency is in fact not moving forward with its proposed payment collapse of E/M codes in 2019. AMA President Barbara McAneny said a two-year window will give the association’s work group ample time to make recommendations on future E/M changes. 

“The panel members have deep expertise in defining and valuing codes, and as members of various specialties, they all use the office visit codes to describe and bill for services provided to Medicare patients,” McAneny said in a statement. “The group is analyzing these issues and plans to offer solutions to be provided to CMS for future implementation.” 

The American Hospital Association also applauded changes to the rule that retain the agency’s “gradual and flexible approach” to quality measurement programs.

Some providers are still worried, though.

Ashley Thompson, AHA’s Senior Vice President of Public Policy Analysis and Development​, said in a statement that the association is disappointed in the reductions made to payments for new drugs.

Anders Gilberg, Senior Vice President of Government Affairs at Medical Group Management Association (MGMA), applauded the rules that reduce documentation requirements in 2019 but was a bit more critical of the plans for 2021.

“Blending payments rates in 2021 won’t necessarily reduce burden, especially with CMS’s newly required add-on codes,” Gilberg said in a statement. “MGMA will continue to examine the rule, leverage feedback from members, and work with CMS to create meaningful burden reduction for physician practices across the country.”

CMS will also continue to exempt some providers from the Merit-based Incentive Payment System. AMGA’s Penso said the group is “puzzled” by this decision.  

“On one hand, CMS is speeding toward value-based care by accelerating the transition to risk-bearing models in the MSSP,” Penso said. “At the same time, CMS is excusing other providers from having to consider moving toward value at all. It’s disappointing and seems to be at odds with CMS’ stated goals regarding value-based payment.”

AHA urged CMS to improve its payment methodology to “better account for the fact that the outpatient payment system includes many more services in its payment rates than the physician fee schedule.” 

Healthcare Dive – Latest News