American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Regulatory History and Advocacy

E/M Coding Changes Timeline
E/M Coding Changes Timeline

 

Medicare Physician Fee Schedule (MPFS) Rulemaking Process

July 2017—CY 2018 MPFS Proposed Rule

CMS requested stakeholder feedback on how to reform the E/M documentation guidelines, reduce associated burden, and better align E/M coding and documentation with the current practice of medicine. The Agency specifically sought comment on whether it would be appropriate to remove its documentation requirements for the H&P exam for all E/M visits at all levels, and also considered eventually allowing MDM and/or time to serve as the key determinant of E/M visit level.

The ACS agreed with CMS that the E/M documentation guidelines should be modified, noting that the current system requires unnecessary documentation, sometimes obscuring relevant and necessary information for patient care. However, the ACS did not support removing documentation requirements for the H&P exam for all E/M visits at all levels and recommended that CMS engage in a process to examine ways to streamline the H&P exam documentation requirements. In addition, the ACS opposed the use of time as the key determinant of E/M visit level—the College stated that using time alone is not appropriate because levels of medical decision-making can be different for different clinicians (for example, a physical therapist compared to a vascular surgeon), and although time is relevant and important to the assessment, medical decision-making is the most essential. The ACS urged CMS to explore the role of medical complexity, risk of medical decision-making, and other factors that incorporate aspects of the patient’s overall state of health into a new weighting of the E/M documentation requirements.

Read the ACS’ comments to the CY 2018 MPFS proposed rule

November 2018—CY 2019 MPFS Final Rule

CMS finalized changes to the payment rates for E/M codes in 2021. For office/outpatient visits, CMS intended to combine E/M levels 2, 3, and 4 for new patients into a single payment rate and will combine E/M levels 2, 3, and 4 for established patients into a separate single payment rate. CMS also created additional add-on codes for primary care and certain specialized services.

The ACS did not support the collapse of work RVU values into one single rate under the MPFS because this amount is based on a calculation of several values, and CMS offered no assurance that the underlying math used to derive this single value correctly reflects the resources used to deliver care across the spectrum of U.S. health care professionals. Furthermore, a number of other unknowns remained with regard to this policy, such as how the single payment rate for levels 2 through 5 would affect physicians compensated through RVU-based payment structures. The ACS also opposed the finalized add-on codes for primary care and certain specialty care services, which would apply to specific specialties rather than the overall care of complex patients. Consequently, such codes would result in increased payment to certain specialties but not others that provide the same services.

Read the ACS’ comments to the CY 2019 MPFS final rule

November 2019—CY 2020 MPFS Final Rule

CMS finalized new changes to its coding and reimbursement policies for office/outpatient evaluation and management (E/M) visits to align with those developed by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel. Beginning in CY 2021, the Agency will retain the five-level office/outpatient E/M coding system for established patients and reduce the number of levels to four for new patient visits. CMS will adopt revised E/M code definitions created by the CPT Editorial Panel, which eliminate history and physical exam as elements for E/M code selection and allow physicians to choose the E/M visit level based on the extent of their medical decision making or on time spent with the patient.

Additionally, CMS accepted the AMA Specialty Society Relative Value Scale Update Committee’s (RUC)-recommended payment rates for office/outpatient E/Ms for CY 2021, which will increase the values of most of these services. However, the Agency will not apply such increases to postoperative E/M visits that are bundled into 10- and 90-day global surgical packages.

The ACS commented extensively on this proposal and expressed its opposition to CMS’ failure to apply increases to standalone office/outpatient E/Ms to global surgical packages. The College’s comments stressed that this revaluation will disrupt the relativity of the MPFS because it will increase payment to certain specialties but not to others that provide the same services. CMS’ policy also will pay different specialties different amounts for the same work, which is prohibited by law. In addition, the Agency ignored the recommendations of nearly all medical specialties when this policy was discussed at the RUC, which voted overwhelmingly to recommend that the full increase of work and physician time for standalone office/outpatient E/Ms be included in global codes. The College does not support any policies that unfairly result in lower reimbursement for surgeons and has continued to contest CMS’ failure to increase values for the E/M portion of 10- and 90-day global surgical packages.

Read the ACS’ comments to the CY 2020 MPFS final rule