The Centers for Medicare & Medicaid Services (CMS) reimburses physicians for care furnished to Medicare Part B beneficiaries based on the Medicare Physician Fee Schedule (PFS), which lists the payment rates for more than 12,600 unique covered services. The PFS contains the resource costs associated with the physician work, practice expense and malpractice insurance for the current procedural terminology (CPT) and Healthcare Common procedure Coding System (HCPCS) codes that represent office visits, surgical procedures, anesthesia services, diagnostic tests, and a range of other therapies. The rule also addresses Medicare billing requirements, quality standards, program integrity, and other issues impacting physician practices.
CMS updates the PFS annually, and publishes a Proposed Rule to allow for public comment before finalizing its policies. Since a large portion of surgeons’ performance and reimbursement is measured and paid for under the PFS, the American College of Surgeons (ACS) closely reviews and provides feedback on the rule to the Agency each year.
CMS finalized several major proposals changing how evaluation and management (E/M) office and outpatient visits are documented and paid for, but postponed the effective date of these policies for two years. Starting in 2021, CMS will combine office/outpatient E/M visit levels 2, 3, and 4 into a single payment rate for new patients, as well as a single payment rate for established patients. The Agency will also create add-on codes for primary care and certain specialized services. In addition, CMS will allow clinicians to report E/M codes using either the current 1995/1997 documentation guidelines, by medical decision making alone, or by time alone.
For 2019, the Agency revised two other E/M documentation requirements so that (1) physicians may choose to focus documentation on what has changed since an established patient’s last visit rather than re-recording elements of the patient’s history and physical exam that are still accurate and up-to-date, and (2) physicians may forgo re-documenting the chief complaint and history that have been noted in the medical record for new and established patients.
As required by the Medicare Access and CHIP Reauthorization Act (MACRA), CMS began collecting data in 2017 on the number and level of postoperative E/M visits (reported using CPT code 99024) related to 10- and 90-day global codes. According to the Agency, the results of this survey suggest that only 4 percent of 10-day global procedures had one or more matched visits associated with 99024; CMS noted in the 2019 PFS that it is possible that clinicians are not consistently reporting postoperative visits, but did not rule out the possibility that these visits are not actually being provided if they are not reported. The Agency is currently surveying three additional codes for data related to postoperative E/M visit levels.
The ACS has produced the following materials further describing how the PFS impacts surgical practice: