The 2019 Physician Fee Schedule and Quality Payment Program final rule has come out.

The Centers for Medicare & Medicaid Services (CMS) announced they are not going to make changes to payment for E/M until at least 2021. CMS Administrator Seema Verma announced: “We know that this is going to have a tremendous impact on many doctors in America, and we want to make sure we get this right.”

Reducing E/M Burden

The AMA had praised the efforts by CMS to reduce the burden imposed by the current E/M documentation rules but they were concerned that the proposed payment structure with a single payment level for new patients (99202-99205) and a single payment level for established patients (99212-99215) and basing the E/M level on the current calculation of MDM left “a number of unanswered questions and potential unintended consequences”. The AMA had asked that the change be delayed for one year, until 2020 and that a work group be convened to better address how the changes to reduce the burden on providers for E/M documentation be developed over the next year, in time for the 2020 fee schedule.

CMS finalized some of their proposed changes and delayed changes to reduce the burden on documentation, coding, and payment until calendar year 2021. CMS issued a fact sheet. The current documentation, coding, and payment for E/M visits will continue for the next two years under either the 1995 or 1997 documentation guidelines.

The proposed payment changes, which collapse the payment steps for the multiple levels for outpatient new patients and established patients is also being delayed until 2021. They have changed how they are viewing the single rates based on the feedback that CMS received from the Proposed Rule. Instead of collapsing levels 2-5 (99202-99205 and 99212-99215) into one as proposed payment for new patients and one for established patients, CMS is collapsing the first four levels (99201-99204 and 99211-99214 (into one payment for each of new patient and established patient and has kept a separate higher payment for the 5th level, 99205 and 99215.

No Reduction for E/M

CMS has also decided to not reduce payment for E/M services provided on the same day as minor procedures. They have also decided to not create separate coding and payment for podiatric E/M visits. Standardized allocation of practice expense relative value units for certain codes have also been scrubbed for now.

Some other things that are being implemented include:

• Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit.
• For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so:
  • Does this mean that an E/M note will no longer have to support the service in the vacuum of just that note?
• CMS clarified that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.
• Removal of potentially duplicate requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

CMS is adding two new G codes for services furnished using communication technology:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS Level II G2012) and
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS Level II G2010)

Providers may be separately paid for a brief communication technology-based service when the patient checks in with the provider via telephone or other telecommunications device to decide if an office visit or other service is needed. This is designed to increase efficiency for providers as well as provide convenience for beneficiaries.

The conversion factor for 2019 physician fee schedule is $36.04, which is a small increase over the 2018 conversions factor of $35.99.