The Potential Impacts of a Flat Rate EM Reimbursement on our IndustrySeptember 26th, 2018 - BC Advantage
The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry?
First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the reimbursement model—and the documentation relaxation proposal. Then you will be challenged to share your opinion attending how this will impact the coding and auditing profession and healthcare in general.
Proposed Reimbursement Model Change
CMS is proposing to “collapse” the current office/outpatient E&M code (99202-99205 & 99212-99215) reimbursement. What this would mean is that regardless of which of these E&M codes are billed, CMS will reimburse one flat rate. CMS has offered their proposed Work RVU and Practice Expense RVU suggestion (this does not include Malpractice RVU), and using the 2018 conversion factor of $35.99, the proposed reimbursement rate change would be approximately $130 for a new patient service and $88 for an established patient encounter. Thus, if you are a practice that
CMS has proposed G codes that would be used as an add-on code to represent additional revenue opportunities for
GPC1X: This is a new code that would add-on to only the established office/outpatient CPT Code. The proposed description states, “Visit complexity inherit to evaluation and management associated with primary medical care.” This code would be used only for primary care services to capture additional resource cost beyond those involved in the base E&M service.
- This code would only be used for established patient care.
- CMS states that they would expect this code to be billed on every primary care established patient.
- This code is not reimbursing for services that could be otherwise reimbursed and it is only reimbursing for face-to-face services.
- While the code is proposed for primary care which generally impacts family practice, internal medicine, and general medicine, CMS is accepting comments regarding “other specialties” (e.g., OB/GYN or Cardiology) who are acting in the role of primary care.
- It could also be appended as an add-on service to the new prolonged services code which we will discuss later in this article.
GCG0X: A proposed new code to add-on to the report office/outpatient CPT Code. The proposed description for this G code states, “Visit complexity inherent to E&M associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/GYN, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care.” These specialties were identified, because, although not all services include surgical intervention, the encounters demonstrate increased complexity. CMS indicates that they would also expect that this code would be used on nearly all specialty office/outpatient E&M encounters as well.
GPRO1: While a current code exists for prolonged physician services, a new G code has been created. The proposed description states, “Prolonged Evaluation and Management or psychotherapy service beyond the typical service time of the primary procedure.” This new code relieves the heavy burden of meeting an additional hour above the base
Proposed Documentation Relaxation
CMS tells us the reason they are suggesting the reimbursement model change is that they are proposing to significantly modify documentation requirements. Essentially, your provider will not be required to exceed the documentation of what is currently required for a level 2 encounter regardless of what level they are billing. To clarify, your provider will only be required to document one (1) HPI element, one (1) organ system on
While there are other new codes proposed and other documentation change considerations, these are the most impactful. Simply stated:
CMS is essentially throwing documentation guidelines and requirements out of the window, but in exchange, they are modifying the reimbursement because of the administrative relief this change would create.
Therefore, if accepted as proposed, your provider could bill any level of service in the office and document essentially whatever they want and it would be reimbursed at one flat rate. This also means that a splinter in the finger would reimburse at the same rate as a diabetic patient with MRSA and a gangrenous non-healing ulcer of the leg.
The Positives and the Negatives
As with most controversial topics, there are those who are in favor
Less Work, More Time
It would seem that if there are minimal documentation burdens, then there would be more time for patient/visit centered care, but will that really translate? The hopeful answer is yes, but more of the potential reality is no. Providers who treat complex patients with extensive care needs tend to bill the current high-level office/outpatient E&M codes, but based on the current proposed RVUs, level 4 and 5 visits may see up to a $70 reimbursement reduction. Therefore, a provider would need to increase their volume of patients to mitigate the lost revenue.
Based on the principle of flat rate reimbursement, will complex patients have difficulty in getting the care they need? The hopeful answer is no more so than they may have now, but the forced reality may certainly have an impact here. Oftentimes, people get upset when you discuss healthcare as a
Healthcare Provider Shortage
We are purportedly experiencing a physician shortage of about 120,000 in the U.S. Will these changes help reduce the shortage, increase the shortage, or will it have no impact? By relaxing the administrative burdens associated with documentation, there is a vote for a positive impact here in hoping this would help reduce the shortage. However, the flat rate reimbursement model may accelerate this shortage in that over time, there will be a continued decline in physician wages influencing career path decisions. Many would say that this may have no impact among most of those in the age bracket of choosing a career path as they likely do not know or understand the documentation requirements of E&M services.
Electronic Medical Record Services
Many EMR vendors have hung their hats on the reduced administrative burden that EMRs would provide to the healthcare industry, and some people think CMS tried to use that as a positive selling point when they “forced” providers to move to EMR or face reimbursement reductions. Now, by proposing to essentially eliminate documentation requirements, the value need for an EMR just took a nose dive. EMR would still have its place of electronically housing something that would otherwise be paper, but isn’t that what Google Drive or a One Drive platform does and for a lot cheaper and with less confusion? EMRs do have many efficiencies, such as marrying the practice management systems to complete a circle of life for an RCM process. But will these extraordinary platforms, templates, and scoring wizards be required to the extent needed now? It doesn’t seem so as this change poses risk to securities that many of the EMR giants have been basking in over the past 8-10 years.
Carriers and Audit Enforcement Agencies
While those on the physician side of business would be thrilled to see the carrier auditors and organizations, such as RAC, ZPIC, HEAT, etc. cease to exist, the potential decreased demand for audits and reviews of almost half of the services submitted to CMS could pose a threat to the availability of jobs in this line of work. While there certainly exists a full exploit of services and processes available for carrier review, the most confusing, and according to the OIG’s 2012 Coding Trends of Medicare E&M Services, codes with the largest potential for fraud and abuse would no longer have documentation requirements. This one truly is a positive and
Coding and Auditing Profession
I saved this one for last as it is the one closest to home for many of us. As a coding or auditing professional, how do you feel this change will impact your job and the job market for others? Don’t forget about coding and auditing educators as well. I have stood before many audiences and said these
When the revenue is no longer impacted by the coding/documentation/billing of these services, then the job opportunities could begin to rapidly decline. The careers we have built, the professionals we have matured into within healthcare, could certainly face hardships as jobs begin to decline. Will this be a consideration in the overall proposed redesign of these E&M codes? Probably not, but it should be your concern if you are a coder and/or auditor.
Wrapping It Up
While it is nice to hear others’ opinions, I challenge you to form your own!
Go to the full 1,472-page document and take the time and read pages 322-377 (it’s only 55 pages and
My opinion attending these proposed changes is that what we have
Please submit your comments to CMS by September 11,
- Submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”
- Mail written comments to:
Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
P.O. Box 8016
Baltimore, MD 21244-8013.
Allow sufficient time for mailed comments to be received before the close of the comment period.
- By express or overnight mail. You may send written comments to:
Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850.
- Deliver (by hand or courier) written comments before the close of the comment period to:
Centers for Medicare & Medicaid Services, Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW., Washington, DC 20201
Link to the full proposed rule:
Shannon DeConda, CPC, CPC-I
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
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