Internists tell CMS not to proceed with changes to payments for E/M services

September 10, 2018, American College of Physicians

Proposed changes to payments for evaluation and management (E/M) codes do not appropriately recognize the value of cognitive care required to treat complex patients, and the proposal should not be implemented, says the American College of Physicians (ACP). The changes are part of the proposed 2019 Medicare Fee Schedule (MFS) and Quality Payment Program (QPP) rules. In comments to the agency, ACP noted that while they are supportive of the proposal to reduce documentation burden for E/M services—something that ACP has been asking CMS to address for several years—that those improvements should not be contingent on acceptance of the payment changes, and CMS should take the time to work with physicians to "get it right," rather than hastily imposing an arbitrary deadline next summer.

"ACP recognizes key improvements the proposed rule makes in reducing documentation burdens for E/M services that are aligned with our Patients Before Paperwork initiative, however, we believe that the proposal to pay the same for complex cognitive care as more basic care will undermine patients who need our help the most," said Dr. Ana María López, MD, MPH, FACP, president, ACP. "As proposed, a considerable number of physicians would be disadvantaged if they treat patients who are frail, sick, or more complex, and would be discouraged from spending time with them."

ACP's comments to the agency were part of a letter submitted today to CMS Administrator Seema Verma and signed by Dr. Jacqueline Fincher, MD, MACP, chair of ACP's Medical Practice and Quality Committee. In addition to discussing the proposed changes to E/M codes, the letter included ACP's full set of recommendations and concerns on the proposed rules for the 2019 fee schedule and QPP, as well as recommendations on alternatives, in lieu of CMS's flat fee proposals.

"ACP believes that CMS should work with the physician community to consider alternative solutions that would ease documentation burdens, but restructure how E/M services are paid. Documentation reduction is instrumental in addressing concerns physicians across the country face, including EHRs and note bloat," said Dr. López. "ACP is open to developing and pilot-testing blended payment alternatives, if they allow for differentiation in payment rates so that more complex E/M services are paid more than less complex ones, and simplify documentation requirements while addressing CMS's program integrity concerns."

Among the additional issues covered in the letter, ACP recommended:

  • Several improvements to the Merit-based Incentive Payment System (MIPS): Reducing administrative burden in MIPS; reducing MIPS complexity, including streamlining scoring across categories; increasing program flexibility; and maximizing MIPS participation, including finalizing the proposed "opt-in" option for those currently excluded under the low-volume threshold.
  • Continuing a gradual MIPS implementation approach by not increasing the weight of the Cost Category as new measures are introduced nor doubling the MIPS performance threshold based on non-MIPS data.
  • Allowing for a more gradual implementation of 2015 Certified EHR Technology (CEHRT).
  • Avoiding low-reliability measures in selecting measures for the Quality Performance Category of MIPS, including the proposed episode-based cost measures.
  • Providing more opportunities for small and rural practices to succeed under QPP.Supporting implementation on January 1 of proposals to pay for virtual visits and other non-face-to-face cognitive services.

"We encourage CMS to take into consideration the comments that ACP and other physician organizations will be submitting as the agency finalizes these rules, in particular their proposed changes to E/M codes," said Dr. López. "We want to work with CMS toward a plan that would reduce E/M documentation burdens while preserving appropriate payment levels for more complex cognitive care."

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