Health Law Daily CMS proposes single payment rate for Levels 2-5 E/M visits
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Friday, July 27, 2018

CMS proposes single payment rate for Levels 2-5 E/M visits

By Kathryn S. Beard, J.D.

Calling the coding, payment, and documentation requirements for evaluation and management (E/M) visits "overly burdensome and no longer aligned with the current practice of medicine," CMS proposed a single payment rate for E/M visits that currently are labeled Level 2 through Level 5 for 2019. In its Proposed rule for the Medicare Physician Fee Schedule (PFS), CMS announced its intention to pay a flat fee of $135 for new patients and $93 for established patients for these type of visits. The Proposed rule for the 2019 PFS, which pays Medicare Part B providers through the Quality Payment Program (QPP), would also allow more types of clinicians to participate in the Merit-based Incentive Payment System (MIPS), advance virtual care, streamline and reduce other reporting requirements. The Proposed rule also implements parts of the Bipartisan Budget Act of 2018 (BBA) (P.L. 115-123) and makes changes to the Medicare Shared Savings Program (MSSP); to ensure consideration, comments on the proposals must be received by September 10 (Proposed rule, 83 FR 35704, July 27, 2018).

E/M visits. The Proposed changes deal with E/M visits that take place in an office or other outpatient setting for new patients (Current Procedural Terminology® (CPT®) codes 99201-99205) and established patients (CPT codes 99211-99215). Currently, these codes represent E/M visits coded at five different levels, increasing in difficulty and with corresponding payment rates. For example, E/M office visits for new patients are currently reimbursed at $45 for Level 1, $76 for Level 2, $110 for Level 3, $167 for Level 4, and $211 for Level 5. The Proposed rule would replace the payment rates for Levels 2 through 5 with a flat rate of $135. As a result, providers performing a Level 2 E/M visit for a new patient would receive a payment increase of $65, but providers performing a Level 5 E/M visit would receive $76 less than they currently do, leaving some concerned that physicians who treat sicker patients will be penalized by this change.

CMS explained in the Proposed rule that the current set of 10 E/M CPT codes does not appropriately reflect the complete range of services and resource costs associated with providing these services, and that the documentation required to distinguish between the codes is burdensome. The agency is also proposing to create new add-on codes for E/M visits to require less documentation and better capture the differential resources involved, because stakeholders have told the agency that the coding structure itself does not reflect these differential resources. The proposal, therefore, would give practitioners the choice to use 1995 guidelines, 1997 guidelines, time, or medical decision making (MDM) to determine the E/M level and to create a single set of relative value units (RVUs) each for CPT codes 99202 through 99205 and 99212 through 99215 (Levels 2 through 5 of office E/M visits for new and existing patients, respectively).

For more on the other proposed changes, see CMS proposes more MIPS provider types, fewer reporting requirements in QPP Year 3, July 13, 2018.

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