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CMS proposed rule: Paying the same for all office visits regardless of complexity

Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program

Federal Register, Proposed rule, Centers for Medicare & Medicaid Services

II.I.2.c (page 345)

Minimizing Documentation Requirements by Simplifying Payment Amounts

As we have explained above, including in prior rulemaking, we believe that the coding, payment, and documentation requirements for E/M visits are overly burdensome and no longer aligned with the current practice of medicine. We believe the current set of 10 CPT codes for new and established office-based and outpatient E/M visits and their respective payment rates no longer appropriately reflect the complete range of services and resource costs associated with furnishing E/M services to all patients across the different physician specialties, and that documenting these services using the current guidelines has become burdensome and out of step with the current practice of medicine. We have included the proposals described above to mitigate the burden associated with the outdated documentation guidelines for these services. To alleviate the effects and mitigate the burden associated with continued use of the outdated CPT code set, we are proposing to simplify the office-based and outpatient E/M payment rates and documentation requirements, and create new add-on codes to better capture the differential resources involved in furnishing certain types of E/M visits.

In conjunction with our proposal to reduce the documentation requirements for E/M visit levels 2 through 5, we are proposing to simplify the payment for those services by paying a single rate for the level 2 through 5 E/M visits.

In alignment with our proposed documentation changes, we are proposing to develop a single set of RVUs under the PFS for E/M office-based and outpatient visit levels 2 through 5 for new patients (CPT codes 99202 through 99205) and a single set of RVUs for visit levels 2 through 5 for established patients (CPT codes 99212 through 99215). While we considered creating new HCPCS G-codes that would describe the services associated with these proposed payment rates, given the wide and longstanding use of these visit codes by both Medicare and private payers, we believe it would have created unnecessary administrative burden to propose new coding. Therefore, we are instead proposing to maintain the current code set. Of the five levels of office-based and outpatient E/M visits, the vast majority of visits are reported as levels 3 and 4. In CY 2016, CPT codes 99203 and 99204 (or E/M visit level 3 and level 4 for new patients) made up around 32 percent and 44 percent, respectively, of the total allowed charges for CPT codes 99201-99205. In the same year, CPT codes 99213 and 3 and 4 for established patients) made up around 39 percent and 50 percent, respectively, of the allowed charges for CPT codes 99211-99215. If our proposals to simplify the documentation requirements and to pay a single PFS rate for new patient E/M visit levels 2 through 5 and a single rate for established patient E/M visit levels 2 through 5 are finalized, practitioners would still bill the CPT code for whichever level of E/M service they furnished and they would be paid at the single PFS rate. However, we believe that eliminating the distinction in payment between visit levels 2 through 5 will eliminate the need to audit against the visit levels, and therefore, will provide immediate relief from the burden of documentation. A single payment rate will also eliminate the increasingly outdated distinction between the kinds of visits that are reflected in the current CPT code levels in both the coding and the associated documentation rules.

(The proposed payments are on page 349.)

Federal Register - Proposed Rule  (1472 pages):
https://www.federalregister.gov...

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Sniffles? Cancer? Under Medicare Plan, Payments for Office Visits Would Be Same for Both

By Robert Pear
The New York Times, July 22, 2018

The Trump administration is proposing huge changes in the way Medicare pays doctors for the most common of all medical services, the office visit, offering physicians basically the same amount, regardless of a patient’s condition or the complexity of the services provided.

Administration officials said the proposal would radically reduce paperwork burdens, freeing doctors to spend more time with patients. The government would pay one rate for new patients and another, lower rate for visits with established patients.

“Time spent on paperwork is time away from patients,” said Seema Verma, the administrator of the Centers for Medicare and Medicaid Services. She estimated that the change would save 51 hours of clinic time per doctor per year.

“We anticipate this to be a very, very significant and massive change, a welcome relief for providers across the nation,” Ms. Verma said, adding that it fulfills President Trump’s promise to “cut the red tape of regulation.”

https://www.nytimes.com...

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Comment:

By Don McCanne, M.D.

Bizarre. Purportedly paying the same fee for all office visits regardless of the complexity of the care would reduce the administrative time required to code the level of complexity of the visit and would reduce the record keeping requirements even though the complexity level would still be determined and records would still be kept to document the patients' conditions and care.

What this really does is to sharply reduce fees for caring for patients with complex conditions. What does that accomplish? It appears to be yet another attack on the traditional Medicare program. Physicians caring for patients with the greatest health care needs are already being paid marginally low rates for their services, and this reduction will be enough to cause many physicians to bail out. When patients lose their private physicians and have to turn to community clinics for their complex care, many will not be happy. It is likely that this is intended to pressure more patients to sign up for the private Medicare Advantage plans.

Not only is this another step towards privatization of Medicare, it also might place a damper on the enthusiasm for Medicare for all, by discrediting the traditional Medicare program.

Maybe it's time to consider placing all physicians on salary. We could do that by nationalizing our health care delivery system, converting it into a national health service. A single payer, improved Medicare for all seems to be a much less disruptive option, but we do need public stewards who believe in and support Medicare. Vote!

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