Money Matters

Proposed CMS Physician Fee Schedule could cut paperwork and payments

CMS presents a single payment rate for Level 2-5 office visits with reduced documentation requirements.

The 2019 Medicare Physician Fee Schedule proposed rule would apply a single payment rate system for Level 2-5 office and outpatient evaluation and management (E/M) visits in exchange for reduced documentation requirements, according to an AOA public policy analysis of the recently released 1,400-page draft rule.

Specifically, CMS proposes to give physicians three options for documenting those visits.

Those who wish to take advantage of the streamlined paperwork can either (1) document medical decision making or (2) record the amount of time spent with the patients. They can also (3) stick with the current 1995 or 1997 CMS guidelines to determine the level of E/M visit, continuing with existing documentation requirements.

The proposed payment rates would apply regardless of the documentation style the physician selects. If adopted, the proposal would apply single payment rates to CPT codes 99202-99205 and 99212-99215, while accepting a documentation standard similar to that of a current Level 2 visit, unless time is used as the determining factor.

Current/proposed payment rates for new patient office/outpatient visits
New patient CPT code Current payment rate Proposed payment rate
99201 (Level 1) $45 $44
99202 (Level 2) $76 $135
99203 (Level 3) $110 $135
99204 (Level 4) $167 $135
99205 (Level 5) $211 $135

(Photo by Getty Images)
Current/proposed payment rates for established patient office/outpatient visits
Established patient CPT code Current payment rate Proposed payment rate
99211 (Level 1) $22 $24
99212 (Level 2) $45 $93
99213 (Level 3) $74 $93
99214 (Level 4) $109 $93
99215 (Level 5) $148 $93

Streamlined paperwork explained

Under the proposed rule, documentation for established patient visits would focus on what has changed since the last visit or on pertinent items that have not changed. Physicians would not have to re-document a defined list of required elements, such as review of a specified number of systems and family/social history.

For both new and established patients, physicians would be able to review and verify the chief complaint and history information recorded by ancillary staff or the beneficiary, instead of having to re-enter the information.

The rule would also amend documentation requirements for teaching physicians, allowing the physician, resident or nurse to input the extent of the physician’s participation into the medical record.  Current regulations require the teaching physician to personally document their participation.

Complexity adjustments

CMS also proposes a new add-on HCPCS G-code to reflect the complexity and additional resources associated with certain types of primary care services.  The code, known as GPC1X, would cover primary care focused on complex medical issues that affect all of the patient’s health care services, such as treatment of diabetes.

An additional new add-on HCPCS G-code is proposed for specialties including endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management care.

CMS would also develop new HCPCS G-codes for prolonged E/M or psychotherapy services.

Members of the AOA Bureau of Socioeconomic Affairs will review the proposed rule later this week.

5 comments

  1. With the new CMS rule sounds like a huge underpayment. Most office visits are level 4. Often we address 1 new and 2 chronic problems. If level 2 and above are the same the. Why would I address more than one patient issue per visit with this new payment system?

  2. This proposed payment plan would destroy private practice. I estimate a $40,000 loss if this adjustment occurs in the plan. I really hope our organization is lobbying for us on this one.

  3. So the only way to not get screwed over is to allow only one complaint per visit, and insist my frequently level 4 and 5 patients come back, more frequently. This change only benefits the cough and cold doctors that literally only see patients for streps and URIs. Those taking care of complex patients will only take apay cut, and may result in the sickest of patients being dismissed from practice. Why would anyone think that my COPD, noncompliant diabetic with CHF visit should be paid the same as the healthy 22 year old with a cold. This is insane

  4. What EM code would be allowed to be used for ptescrition management and what would be the documentation requirements

Leave a comment Please see our comment policy