More than 150 health care organizations, including the California Medical Association (CMA) and the American Medical Association (AMA), sent a joint letter to the Centers for Medicare and Medicaid Services (CMS), opposing the agency’s proposal to collapse evaluation and management (E/M) code and payment levels. The proposal was included in the draft 2019 Medicare Physician Fee Schedule and MACRA Quality Payment Program rule released earlier this summer.

CMA and AMA appreciate CMS’s genuine desire to reduce documentation burdens on physicians to allow them to focus on patients over paperwork. Several of the documentation policy changes included in the proposed rule would go a long way toward alleviating this problem and we have urged their immediate adoption, including:

• Changing the required documentation of the patient’s history to focus only on the interval history
• since the previous visit;
• Eliminating the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or by the patient; and
• Removing the need to justify providing a home visit instead of an office visit.

Implementation of these policies will streamline documentation requirements, reduce note bloat, improve workflow, and contribute to a better environment for health care professionals and their Medicare patients.

However, CMS’ proposal would also modify E/M services through collapsing codes and payment levels. AMA looked at the specific impact on separately reported office visits and summarized the specific E/M impact by specialty. There is a net national reduction given the current distribution of E/M codes of close to 4 percent, with some specialties seeing reductions of up to 20 percent.

CMA and AMA believe there are a number of unanswered questions and potential unintended consequences that would result from the coding policies in the proposed rule. We oppose the implementation of this proposal because it could hurt physicians and other health care professionals in specialties that treat the sickest patients, as well as those who provide comprehensive primary care – ultimately jeopardizing patients’ access to care.

The letter also urges that the new multiple service payment reduction policy in the proposed rule not be adopted as the issue of multiple services on the same day of service was factored into prior valuations of the affected codes.

Positive elements in the CMS proposal include:

• New payments for physician services that are not part of a face-to-face office visit (virtual check-ins, remote consults of patient videos and photographs, and online consultations with other physicians).
• Continuation and expansion of the low volume threshold exception policy to exempt small practices from the Merit-Based Incentive Payment System, but only on a voluntary basis for those who want to participate.
• A reduction in problematic measures in the Promoting Interoperability provisions (formerly Meaningful Use and Advancing Care Information)
• CMA-sponsored geographic payment updates for California physicians.

For more information:

• AMA Summary of the Proposed Rule
• California Geographic Payment Impact Analysis
• Specialty Specific Impacts Including Payment Accuracy Adjustments
• Estimated Impact of CY2019 Evaluation and Management Proposed Policy by Medicare Specialty
• Estimated Impact on Total Allowed Charges by Specialty

CMA and AMA will be submitting comprehensive comments by the September 10 deadline.