In July, the Centers for Medicare and Medicaid Services (CMS) released the proposed Medicare Physician Fee Schedule for 2019. The proposed rule addresses payment, policy and regulatory requirements for Medicare Part B providers in the coming year and suggests major changes in the documentation requirements linked to reimbursement for E/M services. Changes proposed include the following:

• Collapsing payment for new patient and established patient E/M office visit from 5 to 2 payment levels. The new payment system would retain the existing level 1 office visit and combine levels 2-5 office visits into a single averaged payment rate.

• Reducing documentation requirements for E/M established patient visits. Providers would need only to justify a level 2 visit (but can code for a level 2, 3, 4, or 5 visit):
  • Allowing a new option to allow physicians to select a code based on the total length of the visit even if the counseling did not dominate the service time.
  • Allowing physicians to select their level of service for both new and established patient office visits using only medical decision making component.
  • Creating two new codes to allow add-on payment for primary care and specialty care when details of implementation are limited.
• Allowing payment for non-face-to-face “virtual check in” contacts. Virtual check-ins would be defined as technology based non-face-to-face communications with patients (5-10 minutes) to judge if an E/M visit is needed. Communications that fall within 7 days of an E/M visit and/or result in an E/M visit within the next 24-hours or soonest available appointment would be considered bundled with the E/M visit payment.
• Paying for review of and response to patient inquiries with accompanying information/images submitted via technology (e.g., email).  In what CMS describes as “Remote Evaluation of Pre-Recorded Patient Information,” the agency is proposing a code to cover when patient-initiated pictures or videos are sent to physicians for their evaluation of whether an office visit is required. This is distinct from the “virtual check-in” in that it requires review of a patient-initiated image.
• Paying for interprofessional consultations performed via technology such as telephone or internet, with the payment varying based on the amount of time spent on the consult.
• Reducing payment for multiple procedures. CMS is proposing to reduce payment by 50 percent for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier -25.

These proposals, when combined, will have significant redistributive effects on payments for E/M services across physician providers. While CMS has provided projections about specialty specific impacts, CMS projects fail to take into account how many of these provisions would interact, potentially leading to exaggerated impacts.  If implemented, the size of the impact on any provider or group of providers will depend on the mix of services, particularly the proportion of high level office visit services.

The proposed rule also includes a number of seemingly random and unexplained reductions in practice expense costs across several medical specialties.

Estimated Impacts as Projected by CMS
Below are the specialty impacts for policies in the proposed rule, as estimated by CMS.

Table 21- Unadjusted Estimated Specialty Impacts of Proposed Single RVU Amounts for Office/Outpatient E/M 2-Throught 5 Levels  

• Critical Care – minimal change to overall payment
• Pulmonary Disease – less than 3 percent estimated decrease in overall payment

Table 94—CY 2019 PFS Estimated Impact on Total Allowed Charges by Specialty

• Critical care - no total impacts
• Pulmonary disease - 2 percent total impacts.

Please note, while the tables seem to indicate fairly small impacts for pulmonary and critical medicine, the ATS has significant concerns with how CMS conducted its impact estimates. The ATS believes impacts will be much larger for pulmonary and critical care than initially projected by CMS. CMS does not provide separate impact estimates for sleep medicine.

What is the ATS Doing About the Proposed Rule?
The ATS, in collaboration with sister pulmonary, sleep and critical care societies, is closely reviewing the proposed rule. ATS is also working with a broad coalition of medical specialties to conduct additional independent analyses of the CMS rule and its projected impact on different specialties to get a more complete understanding of its effect on ATS members.

While the proposed rule is still being reviewed, several concerns are immediately apparent, including

• Significant distribution of payment from providers offering a larger share of high level office visits to providers offering more lower level office visits.
• Elimination of the long-standing tiered office visit E/M coding structure.
• Changes to E/M values will cause payment anomalies in other code families dependent on those values.
• At least for a while, varying payment and documentation requirements for Medicare versus private payers.
• Large reduction in payments to providers who conduct additional services on the same day as an E/M service, e.g. pulmonologists. This may force physicians to schedule office visits and procedures on different days placing additional burdens and costs on patients and practices.