Mixed Bag

Comments submitted to CMS on proposed Physician Fee Schedule rule

The proposed rule would collapse payment for levels 2-5 of both new and established patient office visit codes into two payment rates.

The AOA submitted comments on the 2019 Medicare Physician Fee Schedule proposed rule Monday. The AOA applauds CMS for attempting to reduce paperwork, but also strenuously opposes the proposed payment cuts for evaluation and management (E/M) visits as well as cuts to certain procedures conducted in the same visit.

The proposed rule, if adopted, would collapse payment for levels 2-5 of both new and established patient office visit codes into two payment rates and apply a 50 percent reduction to the least expensive procedure or visit billed using Modifier 25.

The rules are likely to result in unintended consequences for patients by potentially limiting the number of clinical issues that can be handled at one time, the AOA Bureau of Socioeconomic Affairs found. AOA’s delegates and advisors to the AMA RUC also highlighted DOs’ opposition to the sweeping payment changes proposed in comments earlier this month.

In his Sept. 10 letter, AOA President William S. Mayo, DO, encouraged CMS to “decouple the documentation proposals … from the payment methodology, and implement the documentation changes effective Jan. 1, 2019, to provide immediate relief from administrative burden.” Read the full comment letter.

Possible progress on paperwork

The most positive aspects of the proposed rule support the CMS Patients Over Paperwork initiative, which seeks to ease regulatory burden for physicians.

The 1,400-page proposal includes streamlined documentation requirements. Paperwork for established patient visits would focus on what has changed since the last visit or on pertinent items that have not changed. Physicians would no longer need 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.

Payment cuts ignore complexity and efficiency

The one-size-fits-all approach to E/M billing is a significant point of contention for AOA and other physician groups because it doesn’t address the complexity of patients or improve payment accuracy for multiple E/M visits.

More concerning, private insurers could follow CMS’s lead if the payment changes are adopted in the final rule, making it impossible for physicians to renegotiate contracts with payers before the beginning of the year, Dr. Mayo noted.

Patient care could also suffer under the proposed multiple procedure payment adjustment, which would cut some payments in half when physicians provide several services on the same day as an E/M visit with Modifier 25.  Elderly patients with complex medical conditions may be required to schedule multiple office visits to manage their care, resulting in multiple co-pays for those who are least able to afford it.

“An undertaking of this magnitude cannot be accomplished within a mere 60-day comment period. Given past failed reform attempts and the significant impacts the changes will have on Medicare beneficiaries, primary care practitioners and specialists alike, we urge CMS to delay finalizing changes,” Dr. Mayo wrote.

Further reading:

Proposed CMS Physician Fee Schedule could cut paperwork and payments

DOs receive international recognition as fully licensed physicians


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