Ups and Downs, MACRA Modifiers, and E/M DGs in MPFS 2018 Proposed Rule

EHR documentation

Part 3 of our proposed rule extravaganza is about the Medicare Physician Fee Schedule (MPFS) 2018 proposed rule. (Part 1 was QPP and Part 2 was OPPS). Let’s get down to business, checking out some highlights explained in recent issues of Medicare Compliance and Reimbursement.

Plusses and Minuses

The proposed 2018 conversion factor is 35.99, up 0.1 from the 2017 CF of about 35.89. CMS estimates the overall update to payments is +0.31 percent. That’s the 0.5 percent increase established under MACRA minus 0.19 percent for missing out on statutory misvalued code targets.

The estimated combined impact based on RVUs ranges from +3 percent for clinical social workers to -6 percent for diagnostic testing facilities, if the proposed MPFS goes through.

Keep in mind: The percentage the MPFS lists for your specialty may give you a rough idea, but it doesn’t mean that’s what you’ll actually experience. For example, as the American College of Cardiology stated in a summary, the expected decrease of 2 percent for cardiology is based on cardiology as a whole. Individual cardiologists may see a different percentage of change based on the services that cardiologist provides most.

Final tip: Hospitals with off-campus departments should carefully watch the proposed plan to reduce Medicare payments from 50 percent to 25 percent of the OPPS rate in 2018.

MACRA and Modifiers

MACRA and MIPS come up throughout the proposed rule. Coders may be particularly interested in the proposal to use modifiers to indicate patient relationships (more on that here). Under the proposed rule, clinicians may voluntarily report the modifiers starting Jan. 1, 2018. The voluntary reporting approach will allow time to get to know the modifiers and how to use them. The proposed modifiers are below:

  • X1 (Continuous/broad services)
  • X2 (Continuous/focused services)
  • X3 (Episodic/broad services)
  • X4 (Episodic/focused services)
  • X5 (Only as ordered by another clinician).

E/M News for H & E More Than M

You’ve had a long time to learn Medicare’s 1995 and 1997 E/M Documentation Guidelines, but there may be changes coming. Medicare proposes to review the guidelines, starting with the History and Exam components. The stated purpose of the revisions is to reduce administrative burden and bring the guidelines up to date. The challenge will be creating a set of guidelines that people can agree on and that work with current and emerging technology. The proposed rule states this is expected to take more than a year.

The AAFP posted its support for updating the Documentation Guidelines, noting they aren’t in line with today’s use of EHRs and team-based care.

What About You?

If you could overhaul the E/M documentation guidelines, what would be your top priority?


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.

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2 Comments For This Post

  1. Andrew C Says:

    I always enjoy your posts; thank you for the information.

    I’m not confident, however, that the E&M guideline update will benefit clinicians at all. In fact, I feel it might be a way for CMS to justify lower payments because they appear to presume that just because EHR chart notes can be done quickly and in large detail with so-called “copy and paste” options, that this means the provider didn’t really do those services with the detail documented.

    But that’s just my opinion.

  2. Deborah Marsh Says:

    Thanks for the kind words about the posts, Andrew C! I’d be curious to hear more about whether clinicians think their views are heard and taken into consideration during the rule-making and fee-setting processes.

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