Internists note that final CMS payment rule improves on proposed changes to E/M codes

November 3, 2018, American College of Physicians

The American College of Physicians (ACP) appreciates that the final Medicare Physician Fee Schedule and the Quality Payment Program (QPP) rules for 2019 are responsive to many of the concerns that ACP raised with the Centers for Medicare and Medicaid Services (CMS).

"Internists appreciate CMS' decision not to finalize changes in payments for evaluation and management (E/M) services until 2021. We are hopeful that the additional two calendar years leave time for physicians and other health care stakeholders to work together with regulators to develop and test alternatives that preserve higher for more complex, cognitive care,'" said Ana María López, MD, MPH, MACP, president, ACP. "We are pleased that CMS will be moving forward with plans to simplify documentation for such visits, with significant improvements going into effect next year, and with additional streamlined documentation options becoming available later."

Under the final rule, starting in 2021, CMS will begin paying levels 2, 3, and 4 office visits the same flat amount; level 5 visits would continue to get higher payment, as they currently do, recognizing the greater work involved in caring for the sickest patients. The proposed rule would have paid them all the same amount, devaluing complex, cognitive care.

"While we are encouraged that CMS has recognized the principle that more complex, cognitive care should be reimbursed at a higher level by paying more for level 5, we have reservations about paying level 4 visits, the second most complex visits, at the same amount as levels 2 and 3 visits," Dr. López continued. "We look forward to working with CMS on developing, piloting, and evaluating approaches that recognize the value of complex, cognitive care."

ACP is encouraged to see CMS incorporate several of our recommendations in the final rule; however, ACP also expresses continued reservations about some of the final provisions. ACP's recommendations include:

  • ACP is strongly supportive of provisions that would reduce documentation requirements for physicians, reducing unnecessary administrative burdens. ACP thanks CMS for eliminating redundancies and only requiring physicians to document changed information since the last visit for established patients-starting right away in 2019. Additionally, ACP is glad to see that the documentation changes would eventually allow physicians to choose between different options to best fit their practice needs, including enabling them to document based solely on medical decision making. However, these options will not be available until 2021—we would support CMS allowing them to be implemented sooner.
  • ACP is pleased to see that, effective in 2021, CMS has allowed for add-on codes for level 2-4 visits in primary care and certain specialties and for extended visits to account for the value of cognitive work in treating more complex patients. ACP especially appreciates that the changes to the add-on codes equalize primary care payments to specialty payments.
  • ACP is grateful that CMS is not moving forward with proposals to implement the Multiple Procedure Payment Reduction (MPPR).
  • ACP is strongly supportive of payments for new codes for non-face-to-face visits that will be implemented in 2019. Virtual check-ins, e-consultations, and remote evaluation of patient images and videos will improve patient access to care and help control costs.
  • ACP has long advocated for changes to the Physician Practice Information Survey (PPIS) and is extremely encouraged that CMS is considering updating the data source used to calculate indirect practice expenses to improve payment accuracy for physicians.

"ACP is thankful to see that CMS is moving forward, in 2019, with changes to reduce documentation burdens on these same codes. This effort is aligned with ACP goals in the Patients Before Paperwork initiative," said Dr. López.

Additionally, ACP recognizes that CMS was responsive to feedback provided on the proposed QPP rule. Concerns on some provisions remain:

  • ACP appreciates seeing CMS respond to our request for a Merit-based Incentive Payment System (MIPS) opt-in option for practices previously excluded under the low-volume threshold. This will expand participation without increasing burden.
  • ACP supports CMS' ongoing work to identify and remove low-priority, low-value quality measures and to continue working with stakeholders to focus on measures that offer the most promise for improving patient care while minimizing reporting burden on clinicians.
  • ACP supports the 2015 Certified Electronic Health Record Technology (CEHRT) requirement and agrees that using updated standards and functionality can help improve interoperability; however, ACP is disappointed that CMS did not call out the need to provide physicians flexibility as they implement these upgrades over the course of 2019. Rushing implementation of these upgrades to meet a reporting deadline can have serious patient safety risks and is a major expense and burden, particularly to small practices.
  • ACP is encouraged to see CMS continue the consistent risk threshold for Alternative Payment Models (APMs), which will provide consistency and predictability for model developers and will help APMs continue to grow. APMs are vital to the success of the transition to value.
  • ACP is concerned that CMS' finalized changes to the Cost Category, including adding several new episode-based measures despite concerns over low reliability ratings while simultaneously increasing the weight of the Cost Category from 10 percent to 15 percent, despite objections from ACP and other stakeholders. Clinicians should not have their MIPS scores negatively impacted by inaccurate measures.

ACP was pleased to see that the Hospital Outpatient Perspective Payment System (HOPPS) rule, released this morning, finalized site-neutral payments for clinic visits. Equalizing payments across facility types is a longstanding goal of ACP.

"Currently, CMS often pays more for the same type of office visit in the hospital outpatient setting than in the physician office setting, resulting in higher out-of-pocket costs to patients and unnecessary spending by Medicare. ACP agrees with CMS that there is no justification for patients and the Medicare program paying more for a visit to a doctor when the service is provided in an office owned by a hospital than it would for the same type of visit in an independent physician practice," said Dr. López. "This will increase the sustainability of the Medicare program and improve quality of care for seniors."

ACP recognizes that these are promising steps in the right direction, and is encouraged that CMS expressed interest in working with ACP and other organizations on these issues, in particular, the E/M changes.

"ACP will continue to advocate on behalf of the patient care that internal medicine specialists provide to ensure they are adequately valued for their instrumental role in driving high-value care and will look for continual reforms to the QPP to maximize positive patient outcomes while minimizing clinician burdens," concluded Dr. López.

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