Proposed Changes to E/M Documentation and Payment Pose Significant Impact

The 2019 Physician Fee Schedule proposed rule, released by the Centers for Medicare and Medicaid Services (CMS) July 12, outlined significant changes to the way evaluation and management (E/M) services would be documented and paid. In response to concerns regarding the significant burden represented by E/M documentation, CMS proposed to simplify documentation requirements for these services by:

  • Allowing practitioners to document office and outpatient E/M visits using medical decision-making or time, rather than applying the current 1995 or 1997 E/M documentation guidelines. Alternatively, practitioners could continue using the current framework.
  • Expanding current options by allowing practitioners to use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit.
  • Expanding current options for history and exam documentation, allowing practitioners to focus on changes since the last visit or pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information.
  • Allowing practitioners to review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering it.

The documentation simplification is also paired with payment proposals that would:

  • Condense payment for level two through level five E/M services into blended payment rates for new patients ($134.45) and established patients ($91.92).
  • Create add-on codes that can be billed to account for the added value of primary care ($5.41) or specialty care ($13.70), in addition to the blended rate.
  • Apply a multiple procedure payment reduction when E/M services are provided on the same day as other procedures.
  • Create a new code for prolonged face-to-face services ($67.41).
  • Adjust practice expense payment methodology to balance across-the-board changes.

Per CMS calculations, the impact to specialties would be generally modest, as any overall payment reductions would be negated by the increased efficiency, allowing physicians to spend more time with patients. However, any individual practice that treats a large share of patients at the level four and level five end of E/M faces the potential for disruption. For example, a heart failure patient seen by a cardiologist for a level four visit would still be reported as such. In addition, the add-on for specialty care services would be reported. And, if applicable, the prolonged face-to-face service code may also be reported. 

Below are additional examples showing the impact on various levels of new and established E/M visits, as envisioned for specialty care provided to cardiology patients. These significant changes have the potential to streamline practice workflows, but they also redistribute E/M payments across and within specialties to a considerable degree.


2018 Payment

2019 Proposal

2019 Proposal Specialty Add-on (GCG0X)

2019 Proposal Prolonged Service Add-on (GPRO1)

2019 Proposal Specialty Sum

2019 Proposal Prolonged Sum

99202

$76.32

$134.45

$13.70

$67.41

$148.15

$215.56

99203

$109.80

$134.45

$13.70

$67.41

$148.15

$215.56

99204

$167.40

$134.45

$13.70

$67.41

$148.15

$215.56

99205

$210.60

$134.45

$13.70

$67.41

$148.15

$215.56

99212

$44.64

$91.92

$13.70

$67.41

$105.62

$173.03

99213

$74.16

$91.92

$13.70

$67.41

$105.62

$173.03

99214

$109.44

$91.92

$13.70

$67.41

$105.62

$173.03

99215

$147.60

$91.92

$13.70

$67.41

$105.62

$173.03

It is important to note that these changes are only proposed at this stage. The ACC has an opportunity to influence whether/how they are finalized through public comments and direct communication with policymakers. A final rule will be published by Nov. 2 detailing any changes to be implemented before the 2019 fee schedule takes effect Jan. 1.

The College is collaborating with fellow stakeholders, such as the American Medical Association and the Medical Group Management Association, to continue analyzing these proposed changes and evaluating the impacts.

If you have completed any independent analysis on these changes or have other insights on how these changes could decrease administrative burden in your practice, please contact ACC Advocacy staff at AdvocacyDiv@ACC.org. Share additional ideas, concerns or specific care examples with CMS through the public comment process here by Sept. 10. For more detailed information on these proposed changes, access this CMS Fact Sheet.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: ACC Advocacy, Centers for Medicare and Medicaid Services (U.S.), Outpatients, Medicare, Fee Schedules, Medicaid, Physicians, Documentation, Medical Records, Heart Failure, Primary Health Care


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