Hot Topic: Get the Scoop on Proposed MPFS 2019 Changes to E/M Coding and Payment

MPFS 2019 proposed rule

The 2019 proposed Medicare Physician Fee Schedule (MPFS) includes some major potential changes to E/M coding and payment in its 665 pages. Major. Here are the highlights. Just remember that what’s below is proposed and may change before the final rule is implemented.

Here’s the Big Payment News About Levels 2-5

Let’s get right to it. CMS wants to create a single set of RVUs for 99202-99205 (new patient office/outpatient E/M) and another single set of RVUs for 99212-99215 (established patient office/outpatient E/M). That means 99202 would pay the same as 99205, and 99212 would pay the same as 99215. Codes 99201 and 99211 would have their own rates, similar to 2018 levels. The stated goal is to reduce the burden of documenting and selecting codes and bring coding more in line with medical practice today.

  • Proposed for 99202-99205
    • Work RVU: 1.90
    • Physician time: 37.79 minutes
    • Direct PE inputs: $24.98
  • Proposed for 99212-99215
    • Work RVU: 1.22
    • Physician time: 31.31 minutes
    • Direct PE inputs: $20.70
  • Comparison
    • New patient: You might see something around $135 for 99202-99205 under the proposed method, in contrast to the 2018 rates of about $76 (99202) to $211 (99205).
    • Established patient: Codes 99212-99215 may pay about $93 under the new method, as opposed to the 2018 rates $45 (99212) to $148 (99215).

What About Non-Typical E/M Services?

In the proposed rule, CMS called out three E/M variations that have different resource costs:

  • E/M visit in conjunction with 0-day global procedure
  • Primary care (continuous care)
  • Certain specialist visits.

Here’s how CMS proposes to capture the different resource costs:

  • Multiple procedure payment adjustment for E/M visits furnished with procedures with global periods
  • Add-on G codes for visits with additional work
    • One code for primary care (including when performed by specialties like ob-gyn and cardiology)
    • Another code for specialties that typically report level 4 and 5 visits, specifically endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, or interventional pain management-centered care
  • G codes for podiatry E/M services with lower rates than the proposed E/M single-payment rate because podiatrists tend to report level 2 and 3 codes
  • G code for prolonged face-to-face services, with 30 minutes listed in the descriptor
  • Modification of the PE methodology to stabilize indirect PE allocation.

Dig in to Possible Documentation Changes on the Way

If the changes to E/M coding and payment are adopted, watch for more specifics to emerge on how to implement them. Here is an overview of topics in the proposed rule.

  • MDM, Time, or DGs: You may see flexibility in choosing whether to report E/M based on medical decision making (MDM), time, or the current E/M documentation guidelines (1995 or 1997). If this decision goes through, the proposed rule points out some things to keep in mind:
    • Payment: Regardless of which method you choose, payment is the same. In other words, if one provider uses time and another fills out every checkbox in the DGs, they both get paid the same for levels 2-5.
    • Codes: The codes you use will be the same no matter which method you choose. You’ll report from 99201-99215 and the proposed G codes (described above).
    • MDM: Watch for changes in the future to MDM requirements to make them a better source of distinguishing visit levels.
    • Time: The proposal removes the requirement to report based on time only if counseling/coordination of care is more than 50 percent of the visit. The amount of face-to-face time by the billing practitioner is what would count. There are still a lot of details to iron out, such as when do you meet the time requirements for a specific code and how do you document that (and medical necessity, too).
  • Redundant documentation: Currently, a physician can review and update ROS and PFSH already present in the record without having to re-record it. The proposed 2019 MPFS indicates this flexibility may soon extend to the rest of history and exam for established patients, with practitioners focusing visit documentation on what has changed or the areas relevant to that visit. For both new and established patients, you may see the policy change to allow practitioners to review and verify chief complaint and history recorded by ancillary staff without re-entering those elements.

These E/M Restrictions May Go

As part of the changes, Medicare is also considering removing current specific requirements in these situations:

  • Home visits: For 99341-99350, CMS may remove the requirement to document medical necessity of furnishing a home visit rather than seeing the patient in the office, leaving it to the practitioner and patient to decide.
  • Same-day, same specialty: The current rule is that Medicare generally doesn’t pay for multiple E/M visits on the same day if performed by the same physician or physicians of the same specialty in the same group. CMS wants to hear from stakeholders about whether eliminating this rule will line up better with current medical practice where a provider may have multiple specialties (but just one primary Medicare enrollment specialty that matches others in the group), and about whether the impact on Medicare payments may be too big if the change goes through.

Final note: CMS wants to take a step-by-step approach to changing E/M rules and is starting with a focus on office/outpatient E/M. But other E/M visit types may be seeing similar changes, specific to those types, in the future. And don’t forget, all of the changes discussed here are just possible changes and nothing final has been decided (just like in the 2018 MPFS proposal).

What About You?

Are you excited about the E/M changes in the proposed 2019 MPFS? Or do you want to see changes implemented more slowly?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

, , , , ,

Leave a Reply