Less documentation, E/M pay changes proposed in 2019 fee schedule

Big changes affecting physician payment and documentation burdens—especially for evaluation and management (E/M) services—are included in a proposed rule covering the 2019 Medicare physician fee schedule and the Quality Payment Program (QPP).

Issued by the Centers for Medicare & Medicaid Services (CMS), the massive document also includes proposed changes to the QPP’s Merit-based Incentive Payment System’s (MIPS), including changes to the low-volume exemption thresholds and the promoting interoperability performance category.

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The AMA has released an initial summary of the CMS proposals and is working with national specialty and state medical societies to analyze the proposed rule and draft responses to specific items.

The AMA applauds the effort to cut physicians’ documentation burdens. The Association will offer constructive recommendations that advance that goal while ensuring pay policies that allow physicians to deliver high-quality care for seniors.

The Bipartisan Budget Act of 2018 included a provision to increase physician fees by 0.25 percent in 2019. After a budget-neutrality adjustment of -0.12 percent, the fee update is 0.13 percent. For most specialties, this results in a conversion factor of $36.05, compared with $35.99 for 2018.

Changes for E/M fees

A major CMS proposal involves cutting documentation requirements for E/M services while collapsing payment rates for office and inpatient visits. This includes blending new-patient office-visit codes to a single rate of $135. The proposed blended rate for office visits with established patients would be $93. CMS further proposed a $5 E/M office visit add-on payment for primary care services and a $14 add-on payment for certain specialties.

CMS has outlined several options for new E/M documentation requirements. These include allowing physicians to support the medical necessity of an E/M visit using time and no longer requiring the physician to redocument the history of present illness after it has been entered by other staff.    

CMS also proposes to cut payment by 50 percent for the least expensive procedure or visit that the same physician—or a physician in the same practice—furnishes on the same day as a separately identifiable E/M visit.

Expanding telehealth payments

CMS also proposes, consistent with AMA recommendations, to expand pay for remote physiologic monitoring of chronic care patients. CMS will also expand coverage of telestroke and other telehealth services without geographic restrictions and to a patient’s home.   

CMS is asking for comment on the description, coverage and valuation of services such as brief, non-face-to-face appointments via communications technology or “virtual check-ins” and evaluation of patient-submitted photos or videos. 

Movement on MIPS measures, thresholds

For MIPS, CMS proposes retaining the current low-volume thresholds but adding a third criterion: providing fewer than 200 covered services to Part B patients. Another proposal would allow low-volume practices to opt in to MIPS if they meet or exceed only one or two—but not all three—of the low-volume threshold elements.

CMS also proposes to retain bonus points for providing care to complex patients and submitting end-to-end reporting. Maintaining reduced reporting requirements for small practices is also proposed.

The MIPS’ Advancing Care Information category would now be called Promoting Interoperability and CMS is proposing a new scoring methodology to go with the name change. It includes eliminating the base, performance and bonus scoring, and replacing them with a 100-point scale based on individual measures.

The deadline for commenting on the rule is Sept. 10.