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CMS final rule delays coding reforms that affect physician payment

Physician fee schedule and quality payment rule also makes updates to interoperability, telehealth and prescription drug costs.

Susan Morse, Managing Editor

Credit: <a href="">Matthew Bisanz</a>.Credit: Matthew Bisanz.

The Centers for Medicare and Medicaid Services is delaying for two years implementation of evaluation and management coding reforms that affect physician payment, in a move applauded by the American Medical Association.

The final 2019 physician fee schedule and quality payment program rule also includes updates on interoperability, telehealth and drug costs.

Evaluation and management payment involves defining and valuing codes. CMS originally talked about going to two E/M codes, and is now going to three codes, said CMS Administrator Seema Verma.

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Coding requirements for physician services for E/M visits have not been updated in 20 years, Verma said.

But the payment rule delay until 2021 offers more time for stakeholder input, she said.

For 2019 and 2020, CMS will continue the current coding and payment structure for E/M visits and practitioners should continue to use either the 1995 or 1997 EM documentation guidelines.


The AMA said it is grateful the administration is not moving forward in 2019 with the payment "collapse" of E/M codes.

A two-year window for implementation of the proposal gives an AMA-convened work group of physicians and other health professionals time to make recommendations, AMA President Barbara L. McAneny said.

The E/M codes are not designed to save money, CMS said, but streamlining efforts in the rule will simplify the way physicians bill for these visits. It is expected to save clinicians $87 million in administrative costs in 2019, $843 million over the next decade and 21 million hours to 2021.


The rule reduces Medicare Part B drug prices by lowering the wholesale acquisition cost from 6 to 3 percent. The savings gets passed on to consumers, Verma said. Seniors will especially save money on drugs with high launch prices.

The rule, which is part of President Trump's blueprint to lower prescription drug costs, takes effect on January 1, 2019.

Now in Year 3 of the quality payment program, CMS is advancing meaningful measures as part of the agency's implementation of MACRA.

The rule updates the merit-based incentive payment system by giving physicians incentives that are directly tied to updating their EHR systems for patient access.

CMS also introduced an opt-in policy so that certain clinicians who see a low volume of Medicare patients can still participate in the MIPS program.

For the first time, Medicare will pay for remote and telehealth services, and also for remote patient monitoring under a home health rule released Wednesday, that is expected to save $14.2 million. The rule eliminates the requirement to document the medical necessity of a home visit in lieu of an office visit.

CMS is also finalizing policies to implement the requirements of the Bipartisan Budget Act of 2018 for telehealth services related to beneficiaries with end-stage renal disease receiving home dialysis and beneficiaries with acute stroke.

Medicare will pay providers for new communication technology-based services, such as brief check-ins between patients and practitioners, and pay separately for evaluation of remote pre-recorded images and/or video. CMS is also expanding the list of Medicare-covered telehealth services.

Currently, Medicare pays for telehealth services for rural providers.


The rule released Thursday follows through on CMS efforts to reduce physician administrative burden and burnout.

CMS said it is finalizing several burden-reduction proposals immediately, effective January 1, 2019, where commenters provided overwhelming support.

The AMA cited as positive: 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 removal of the need to justify providing a home visit instead of an office visit.


"Among other advances, improving how CMS pays for drugs and for physician visits will help deliver on two HHS priorities: bringing down the cost of prescription drugs and creating a value-based healthcare system that empowers patients and providers," said Health and Human Services Secretary Alex Azar.

"Today's rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community," said CMS Administrator Seema Verma. "Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America's seniors."

"Implementation of these policies will streamline documentation requirements, reducing paperwork burdens that interfere with a meaningful patient-physician relationship," McAneny said. "Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records."

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