CMS Revises Planned E/M Coding Changes in New Medicare Physician Fee Schedule Proposal

Last Updated: Aug 1, 2019

MedicareThe proposed 2020 Medicare Physician Fee Schedule (MPFS) includes changes to the planned overhaul of payment for Evaluation and Management (E/M) services that was introduced in the 2019 MPFS. The Centers for Medicare and Medicaid Services (CMS) announced the proposed rule on July 29, 2019.

E/M Coding Changes on the Horizon for 2021

CMS is proposing these changes to E/M coding, starting during the 2021 calendar year:

  • CMS is no longer planning to collapse payments for office/outpatient E/M visit levels 2-4. Instead, effective Jan. 1, 2021, it will align E/M coding with recent updates made by the CPT Editorial Panel convened by the American Medical Association (AMA).
  • While code definitions for E/M services will change, CMS will retain 5 levels of coding for established patients and four levels of coding for new patients.
  • Clinicians will be able to document the E/M visit level based on either medical decision making or time.
  • CMS is proposing a single add-on code for office/outpatient E/M visits for both primary care and non-specialty care, in place of the two add-on codes associated with primary care and complex specialty care announced in the 2019 MPFS rule.

CMS says stakeholder feedback from the physician and health care community was a major factor in its decision not to implement the single payment rate for levels 2-4 E/M visits. The Pennsylvania Medical Society (PAMED) was among the many organizations and individuals who expressed significant concerns with the collapsed payment rates.

More Highlights of the Proposed 2020 MPFS: Documentation, Chronic Care Management, MIPS & More

Here’s a look at additional highlights of the proposed rule:

  • Documentation Changes for Verification of Medical Records – In an effort to reduce administrative burden, CMS is proposing to allow physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives to review and verify (rather than re-document) notes made in the medical record by other members of the medical team.  
  • Transitional Care Management (TCM) & Chronic Care Management (CCM) – The 2020 MPFS includes an increase in payment for TCM. It also includes a proposal to implement a set of G-codes for certain CCM services, including replacing some CCM codes with Medicare-specific codes that better reflect the additional time and resources needed to treat complex patients.
  • The Addition of Codes for Principal Care Management Services (PCM) – CMS is proposing to add PCM for management of a single high-risk disease or chronic complex condition. PCM services would be used for one serious condition typically expected to last between three months and a year or until death. CMS expects it to be billed by specialists managing one condition. The patient could receive PCM services from more than one clinician.
  • Opioid Use Disorder (OUD) Treatment – CMS is proposing several changes related to opioid and substance use disorder (SUD) treatment, including new telehealth codes for treating OUD, Medicare coverage for OUD treatment services provided by opioid treatment programs, and bundled payments for SUD treatment.
  • Merit-based Incentive Payment System (MIPS) Changes for 2020
    • CMS is proposing to increase the performance threshold to 45 points during the 2020 performance year (an increase of 15 points on the 30-point threshold for 2019).
    • The exceptional performance threshold would increase to 80 points, an increase of 5points compared to 2019.
    • For 2020, CMS is proposing the following performance category weights: 40 percent for Quality (down from 45 percent in 2019); 20 percent for Cost (up from 15 percent in 2019); 15 percent for Improvement Activities (unchanged from 2019); and 25 percent for Promoting Interoperability (unchanged from 2019).
  • MIPS Structural Changes Proposed for 2021 Performance Year – A proposed new framework for MIPS in 2021 – which CMS has termed MIPS Value Pathways – aims to significantly reduce the number of measures on which physicians and other clinicians are required to report. CMS says that, under the new framework, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models.
  • 2020 MPFS Conversion Factor – The proposed conversion factor is slightly higher than last year’s amount. CMS is proposing a conversion factor of $36.09 for 2020, compared to the 2019 factor of $36.04.

What’s Next

PAMED’s Practice Support Team is in the process of analyzing the 1,704-page proposal to determine how our members may be affected CMS’ suggested changes. We will share our analysis with members as soon as it is available.

CMS is accepting public comments on the proposal through Sept. 27, 2019. Comments (referencing file code CMS-1715-P) can be submitted via one of the following methods:

You can find more details on submitting comments here.

Additional Resources

You can find a PDF of the proposed rule online here.

CMS offers these fact sheets on proposed changes to the MPFS and the Quality Payment Program (QPP):

PAMED members with questions can also contact our Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@pamedsoc.org

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