The AMA sent a letter to the Administrator of CMS on August 27, 2018 with signatures from most of the medical societies and state medical societies with comments on the CMS proposal for the “Patients Over Paperwork” initiative.

AMA Loves Paperwork Reduction

In the letter, the AMA says that they support CMS’ initiative to reduce paperwork and administrative burdens for physicians and other healthcare professionals so that more time can be focused on the patients that they are caring for. The letter also brought up that not only do the current guidelines which leads to excessive documentation cause the patient to be short changed, it also leads to “note bloat”, with excessive redundant and irrelevant information,  making it difficult to quickly find the important information about the patient’s illness and most recent test results in order to best determine an assessment and plan for that patient. The AMA and those who sign on to the letter feel that the proposed rule would help to reduce these problems significantly.

They also ask for the following three changes:

• Changing the required patient’s history to focus only on the interval history since the previous visit
• Eliminate the requirement for providers to re-document information in the chart that has already been documented by practice staff or the patient
• Removing the need to justify providing a home visit instead of an office visit

What Does the AMA Want?

I find the first issue interesting, since I teach providers to document interval histories for established patients. The EHR, with the copy and paste function has exploded the presence of redundant information. If the provider just documented that the prior history of “date” had been reviewed and what has changed, an interval history is captured, and the current rules have been meant. The first bullet almost shows that those writing and signing on to this letter do not fully understand documentation of history for established patients.

The second bullet makes sense. If ancillary staff captures the HPI, the provider should be able to just indicate they read and agree with the HPI without having to document the same information again because of the rule that the HPI must be documented by the provider.

The third bullet seems to say that providers wishes CMS and other payers to trust their decision making when the provider determines that the patient needs a home visit, therefore not requiring it to be justified in writing in the note.

I find it interesting that the comments focused on the history when the proposal from CMS was looking at eliminating the history and exam from determining the visit level entirely, depending entirely on the medical necessity of the presenting problem(s).

The letter went on to address the collapsing of the payment rates from the current 8 different payment levels for new and established office patient visits to one for new patients and one for established patients. The letter indicated that the AMA and signers to the letter object to this implementation of this payment structure because it could financially punish providers in specialties that treat the sickest patients. It would also penalize those who provide comprehensive primary care, which will ultimately jeopardize patients’ access to care.

AMA Says No

The AMA also asks CMS to not implement the multiple service payment reduction (when the 25 modifier is used). They said that the that the valuations of the codes have already factored in the concept of multiple services on the same day.

The letter concludes with the suggestion to create a workgroup of physicians and other healthcare professionals with deep expertise in defining and valuing codes and who also use the office visit codes to describe and bill for services provided to Medicare patients. This workgroup’s objective would be to analyze E&M coding and payment issues that are currently encountered and arrive at concrete solutions that can be proposed to CMS in time for implementation for 2020.