The Centers for Medicare and Medicaid Services (CMS) recently announced its “Patients Over Paperwork” initiative, focusing on reducing administrative burden while improving care coordination, health outcomes, and patients’ ability to make decisions about their own care. According to CMS, physicians say they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time away from patient care. Sound familiar? Well, CMS says it is listening to you and is taking action!
In the 2019 Physician Fee Schedule, CMS proposed streamlined documentation requirements to focus on patient care and proposed modernizing payment policies so that Medicare beneficiaries can take advantage of the latest technologies to get the quality care they need.
For 2019 and beyond, CMS finalized the following documentation changes for Evaluation and Management (E&M) visits that do not require changes in coding or in payment:
- The requirement to document the medical necessity of a home visit in lieu of an office visit is eliminated.
- For the history and examination for E&M visits for established patients, if relevant information is already contained in the medical record, physicians may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-document the list of required elements if the physician documents that the previous information has been reviewed and has been updated as needed.
- For the chief complaint and history for E&M visits for new and established patients, physicians are not required to re-document in the medical record information that has already been entered by ancillary staff or by the patient. The physician may simply document in the medical record that the information has been reviewed and verified.
The current CMS documentation requirements differ for each level of care and are based on either the 1995 or 1997 E&M documentation guidelines. Billing Medicare for an E&M visit requires the selection of a CPT code that best represents:
- Patient type (new vs. established);
- Setting of service (outpatient setting or inpatient setting); and
- Level of E&M service performed.
Currently, there are five levels of E&M visits which may be billed for each of new patients and established patients. A Level 1 visit is the least complex visit, and a Level 5 visit is the most complex visit. Medicare pays a progressively higher amount for each level of visit. As part of the Patients over Paperwork initiative, CMS proposes, beginning January 1, 2021, to pay a single payment rate for Levels 2 through 4 E&M visits, while maintaining a higher payment rate for Level 5 visits. Also proposed are add-on codes for Level 2 through 4 visits that describe additional resources utilized in visits for primary care and certain non-procedure specialized care. CMS has also proposed a new “extended visit” add-on code for Level 2 through 4 visits to account for additional resources required when physicians need to spend additional time with patients.
For purposes of documentation, physicians may choose to utilize either the 1995 documentation guidelines, the 1997 documentation guidelines, medical decision-making, or time. If time is used to document the visit, physicians must document the medical necessity of the visit and that the physician personally spent the required amount of time face-to-face with the patient that is required by the CPT code. Documentation required for Level 2 through 4 visits will only require the documentation that is currently required for a Level 2 visit.
The estimated payments for 2021 for each level for established patients are as follows:
- Level 1 -$24
- Level 2-4 -$90 ($103 for primary care)
- Level 5 -$148
- The estimated payments for 2021 for each level for new patients are as follows:
- Level 1 - $44
- Level 2-4-$130 ($143 for primary care)
- Level 5- $211
CMS is also recognizing changes in healthcare practice that incorporate innovation and technology in managing patient care and aims to increase access for Medicare patients to services that are routinely furnished via communication technology. To evidence this commitment, CMS finalized policies to:
- Pay clinicians for virtual check-ins involving brief, non-face-to-face assessments utilizing communication technology.
- Pay clinicians for remote evaluation of patient-submitted photos or recorded video.
- Pay Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for these types of services in addition to the RHC all-inclusive rate and the FQHC prospective payment system rate.
Stay tuned as these programs will surely evolve over the next year to make sure you are prepared for all of the changes to come in 2021.
Written by the attorneys in the Health Law Practice Group at Friday, Eldredge & Clark, LLP, this information is not a substitute for legal advice and should be considered for general guidance only. For more information or if you have further questions, please contact one of our Health Law Attorneys.
Lynda M. Johnson has practiced in the health law area since 1986, representing a wide variety of healthcare providers including hospitals, physicians, physician groups, nursing homes, and home health agencies. Recently, her practice has focused on the representation of hospitals and physicians in HIPAA compliance efforts and other areas of regulatory compliance. Her practice also includes issues involving Stark I and II and Anti-Kickback compliance, Medicare/Medicaid reimbursement, corporate compliance issues, physician and hospital organization issues, managed care, healthcare and hospital law, long-term care and home health.
Timothy Ezell practices primarily in the area of healthcare law, representing hospitals, physician groups and other medical service providers in various corporate and compliance matters. His experience covers matters relating to HIPAA, Stark, fraud and abuse, anti-kickback, EMTALA, Medicare reimbursement, compliance, joint ventures, provider sales and acquisitions, medical staff bylaws and credentialing issues.