CMS final rule aims to reduce physician billing, coding burdens

The Centers for Medicare and Medicaid Services on Friday issued a final rule reducing clinician burden regarding billing and coding requirements for evaluation and management services.

Evaluation and management (E/M) coding is the process by which physician-patient encounters are translated into five-digit Current Procedural Terminology (CPT) codes, which are submitted for payment to Medicare for common office visits.

As part of a new Medicare Physician Fee Schedule final rule, CMS has made changes—effective Jan. 1, 2021—to the “burdensome and overly complicated” E/M documentation and coding framework that dates back to the mid-1990s.

“Clinician burnout is high because outdated government regulations are diverting their attention from what matters—patient care,” said CMS Administrator Seema Verma in a written statement. “The Trump Administration’s final rule brings antiquated requirements, which are over 20 years old, up to date with the current practice of medicine and will impact the current and future generation of clinicians.”

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Specifically, CMS has aligned its E/M coding requirements with changes adopted by the American Medical Association CPT Editorial Panel for office and outpatient E/M visits.

“The CPT coding changes retain five levels of coding for established patients, reduce the number of levels to four for office/outpatient E/M visits for new patients, and revise the code definitions,” according to the agency. “The CPT code changes also revise the times and medical decision making process for all of the codes, and requires performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time.”

In addition, CMS has adopted the AMA Specialty Society Relative Value Scale Update Committee (RUC) recommended values for the office and outpatient E/M visit codes for Calendar Year 2021 and the new add-on CPT code for prolonged service time.

“The AMA RUC-recommended values will increase payment for office/outpatient E/M visits,” states the agency. “The RUC recommendations reflect a robust survey approach by the AMA, including surveying more than 50 specialty types, and demonstrating that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians.”

In a statement, AMA applauded the Medicare final rule for bringing about the first overhaul of E/M office visit documentation and coding in more than 25 years.

“CMS Administrator Verma made it a priority to reduce documentation of E/M office visit services as part of her Patients Over Paperwork initiative,” said AMA President Patrice Harris, MD. “This new approach is a significant step in reducing administrative burdens that get in the way of patient care.”

Harris contends that, to meet the effective date of Jan. 1, 2021, vendors and payers must act now to take the necessary next steps to align their systems with E/M office visit code changes.

“In the coming months, the AMA will undertake an aggressive effort to ensure that EHR providers, coders, payers and other vendors implement simplified coding so physicians no longer labor under undue documentation complexity,” added Harris. “The AMA urges the entire healthcare industry to implement the simplified approach to E/M office visit documentation and coding, and will continue to provide information and resources to help ease this transition.”

In a separate but related action, as part of its Medicare Physician Fee Schedule final rule, CMS says it is “finalizing broad modifications to the documentation policy so that physicians, physician assistants and advanced practice registered nurses (APRNs—nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) can review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, medical, physician assistant and APRN students, nurses or other members of the medical team.”

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