2019 MPFS Proposed Changes

Are YOU Ready?

Have you done the math to know how the proposed 2019 Medicare Physician Fee Schedule (MPFS) changes to Evaluation and Management (E/M) services will affect your practice?

If not – it’s a good idea to know how this monumental change will influence the bottom line for your and your team.

As part of the administrations initiative “Patient’s over Paperwork”, HHS and CMS have proposed sweeping changes to the Evaluation and Management codes that are the backbone of many physician practices.  This code set has not seen a revision for years, since 1997, and this is as transformative as the original publishing of the 1995 guidelines.

As you begin an analysis of the proposed changes to the reimbursement for the E/M codes it is obvious it is not all good news.

The proposal was released in July 2018, through the Federal Register, with a comment period running through September 10, 2018, providing industry stakeholders to opine on the proposed change.  In a nutshell the proposal includes:

  • Reduce payment by 50 percent for the least expensive procedure or visit that the same
    physician (or a physician in the same group practice) furnishes on the same day as a
    separately identifiable E&M visit.
  • Create an add-on payment of about $5 (0.15 RVUs) for primary care office visits via a
    new code GPC1X, visit complexity inherent to evaluation and management associated
    with primary medical care services
  • Create an add-on payment of about $12 (0.33 RVUs) for office visits performed by
    certain specialties via a new code GCG0X, visit complexity inherent to evaluation and management associated with:
    • Allergy/Immunology, Cardiology, Endocrinology, Hematology/Oncology, Interventional Pain Management-Centered Care, Neurology, Obstetrics/Gynecology, Otolaryngology, Rheumatology, or Urology.
  • CMS would also add a new prolonged service code as an add-on to any office visit lasting more
    than 30 minutes beyond the office visit (i.e., hour-long visits in total). The code GPRO1,
    prolonged evaluation and management or psychotherapy services(s) (List separately in addition
    to code for office or other outpatient Evaluation and Management or psychotherapy service),
    would have a payment rate of approximately $67 (1.85 RVUs).

How this breaks down by code is demonstrated in the following table published by MGMA..

This kind of collapsing of the reimbursement will be felt most by those who utilize the higher levels of service such as Cardiology, Nephrology, and other highly specialized practices.  Meanwhile, some general practitioners may recognize an increase in their reimbursement due to how their bell curve for these services fall.

In addition to reimbursement changes, the documentation requirements would also change dramatically.  How this will translate to the templates and electronic health records already in place is still a bit murky.

It appears that CMS is hoping the changes in documentation will be so alluring for the physician community that they don’t notice the reduction in reimbursement.

The documentation overview is as follows:

  • Physicians would be allowed to choose one of the following methods of documentation:
    1. 1995 or 1997 E&M guidelines for history, physical exam and medical decision
    making (current framework for documentation);
    2. Medical decision making only; or
    3. Physician time spent face-to-face with patients.
  • CMS would only require documentation to support the medical necessity of the visit and to
    support a level 2 CPT visit code.
    • CMS assumes that physicians may continue to document
      according to the five levels of codes for clinical, legal, operational and other purposes.
  • In addition, physicians would no longer be required to re-record elements of history and physical
    exam when there is evidence that the information has been reviewed and updated. CMS would
    eliminate re-entry of information regarding chief complaint and history that is already recorded
    by ancillary staff or the beneficiary.
    • The practitioner would only document that they reviewed
      and verified the information.

Another area of concern is the proposed 50% reduction in reimbursement for an E/M service on the same day as another procedure (use of modifier 25).  The use of modifier 25 has been scrutinized for years and with this proposal, the reduction in reimbursement is likely thought to level the playing field of over use of the modifier to boost revenue.

What should you do? Determine the E/M services submitted to Medicare with the 25 modifier and determine what the reduction in payment may mean to your team.

We haven’t seen the final rule yet, next month it is expected, however, it will likely be some form of this proposal.

If you haven’t looked at your documentation habits, your fee schedule, average reimbursement for these codes, and in particular the segment of your patient population paid under the Medicare Physicians Fee Schedule, now is the time to begin looking at how these changes might influence your practice.

On a closing note, as always we have no idea how the other payors in the industry will interpret the final decisions on this from CMS, but it is likely that many will follow along.

Stay diligent my friends, and of course reach out to me if you have any questions about this information provided.

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