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CMA Today | NovDec 2019 13

Take a closer look at CMS policy efforts to reduce the administrative burdens of Medicare E/M services

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f i n e p r i n t

Change is in the works for Medicare. Under a final rule issued November 1, 2018, the Centers for Medicare

& Medicaid Services (CMS) updated poli-cies that impact documentation, coding, and payment for many outpatient services.1

The proposed policy changes are part of

the CMS Patients Over Paperwork initiative

designed to reduce the administrative

burdens associated with outpatient

evaluation and management (E/M) services

for new and established patients.2 These

changes apply to E/M services provided

under the Medicare Physician Fee Schedule

starting on or after January 1, 2019.

However, the policy updates will not be

fully implemented until January 1, 2021.1

Basic changes of any scope to Medicare’s

E/M outpatient services are inherently signif-

icant. After all, medical record documenta-

tion is essential for providing quality patient

care. The facts, findings, and observations

included in the patient’s medical record

continually inform the physician’s clinical

decisions. Accurate and complete records

make it possible for providers to evaluate,

plan, and monitor a patient’s ongoing medi-

cal care. Documentation is also necessary for

health care providers to receive appropriate

payment for the services they provide.

Paperwork and pushbackThe scope of the administrative burdens

associated with documentation, coding,

and payment practices is an issue that

extends beyond Medicare E/M outpa-

tient care. The U.S. health care system is

governed by an extensive and complex

labyrinth of administrative requirements.

There are increasing concerns among

health system leaders that these require-

ments are excessive and may interfere with

health care quality and patient care. Such

concerns are valid. One recent study found

that for every hour providers spend see-

ing patients, providers also spend close to

code. Under the auspices of the AMA, the CPT coding system was first developed in 1966 to offer providers a consistent and accurate way to describe medical treat-ments and services. The CPT code that a provider uses is expected to appropri-ately reflect the patient type (e.g., new or established), the service setting (e.g., outpatient or inpatient), and the level of E/M service provided.

Currently, there are five levels of E/M outpatient visits. Generally, while E/M ser-vices are organized into various categories and levels, a more complex visit means that a higher code level will be billed. In turn, the amount of documentation required increases with the higher service levels, as does the payment rate. When selecting the appropriate level of E/M services, consider three key components7:

• History

• Examination

• Medical decision-making

For visits that mostly involve counseling or coordination of care, the time required can be a decisive factor to qualify for a par-ticular E/M service level.7

Finally, the CPT Editorial Panel of the AMA ensures that CPT codes are up to date and accurately reflect the current state of medical services. The panel meets regularly and is the final authority on coding and coding modifiers.8

In with the newFor 2019, the new guidelines largely involve documentation requirements.9 For example, starting this year providers are required to document the patient’s history since the last visit only, eliminat-ing the need for physicians to redocument information in the medical record that was already documented by staff or the patient.

The CMS fact sheet on changes to the Physician Fee Schedule for 2019 explains:

For established patient office/outpatient

visits, when relevant information is

two additional hours on electronic health record (EHR) and desk work.3

The American College of Physicians (ACP) 2017 position paper, “Putting Patients First by Reducing Administrative Tasks in Health Care,”4 outlines the bur-geoning scope of administrative respon-sibilities that now confront health care providers and describes the far-reaching potential impact of such responsibilities on patient care:

The growing number of administrative tasks

imposed on physicians, their practices, and

their patients adds unnecessary costs to the

U.S. health care system, individual physi-

cian practices, and the patients themselves.

Excessive administrative tasks also divert

time and focus from more clinically impor-

tant activities of physicians and their staffs,

such as providing actual care to patients and

improving quality, and may prevent patients

from receiving timely and appropriate care

or treatment. In addition, administrative

tasks are keeping physicians from entering

or remaining in primary care and may cause

them to decline participation in certain

insurance plans because of the excessive

requirements. The increase in these tasks

also has been linked to greater stress and

burnout among physicians.4

In this context, efforts to streamline Medicare’s documentation requirements

for E/M outpatient services are a long time coming, according to industry experts. “Group practices and clinicians have faced excessive Medicare documentation require-ments and E/M coding policies that haven’t been updated in 20 years,” remarks Mollie Gelburd, JD, associate director of gov-ernment affairs for the Medical Group Management Association (MGMA) in Washington, DC. “It’s a relief now to see some concrete steps to address these issues. When CMS said that it was looking at simplifying documentation and reducing burden, I think this is something that was very welcomed by the provider community.”

Notably, many of the proposed policy changes are still under review. While, as Gelburd notes, efforts to reduce documen-tation burdens are generally supported by the physician community, there are concerns that the proposed coding and payment policy will negatively impact reimbursement and care delivery for more complex types of patient care under the revamped system.

Consequently, pushback from the American Medical Association (AMA) and other groups, as well as feedback from more than 15,000 physicians and other Medicare stakeholders, urged CMS to delay implementation of much of the proposed policy changes until a work group develops an alternative by 2020.5 The delay mostly impacts coding and payment policy proposals.

For the record To put the ongoing dialogue between CMS and critics in perspective, background infor-mation on documentation, coding, and payment systems is worth reviewing.

Documentation requirements for out-patient E/M care vary depending on the level of the visit. They have been based on either the 1995 or 1997 edition of Documentation Guidelines for Evaluation and Management Services.6 These medi-cal services also require the use of the Current Procedural Terminology (CPT)

ResourcesCenters for Medicare & Medicaid Services (CMS): Patients Over Paperwork https://www.cms.gov/About-CMS/sto ry-page/patients-over-paperwork.html

American Medical Association: CPT Editorial Panelhttps://www.ama-assn.org/about/cpt -editorial-panel

Medical Group Management Association (MGMA): Government Advocacy https://www.mgma.com/advocacy /issues/medicare-payment-policies

14 NovDec 2019 | CMA Today

Tabs to track

Medicare E/M services

already contained in the medical record,

practitioners may choose to focus their

documentation on what has changed since

the last visit, or on pertinent items that

have not changed, and need not rerecord

the defined list of required elements if there

is evidence that the practitioner reviewed

the previous information and updated it

as needed. Practitioners should still review

prior data, update as necessary, and indicate

in the medical record that they have done so.1

In addition, the 2019 policy alters

documentation requirements in the

following ways1:

• Allow for the removal of any potentially

duplicative requirements for medical

record notations that were previously

included by “residents or other

members of the medical team for E/M

visits furnished by teaching physicians.”1

• Eliminate the requirement to docu-

ment the medical necessity of a home

visit in lieu of an office visit.

• Remove practitioners’ obligation to reen-

ter information already documented on

the patient’s chief concern and history,

instead allowing practitioners to simply

note the information has been reviewed

and verified in the medical record.

The standout change for 2019 is that

“ancillary staff can now be more a part

of the documentation process, whereas

before they could just take vitals and

Role of documentaWell-prepared documentation of medical records is an essential part of providing patients with qual-ity health care because clear and concise records accomplish several goals14:

• Ensure medical professionals receive correct payments on time.

• Record relevant patient observa-tions, findings, and history.

• Aid physicians in planning patient care.

• Allow tracking of patient health over time.


Write on target

or 1997 documentation guidelines, they would be given the choice to instead docu-ment level 2 through 5 office visits using medical decision-making (MDM) or time. “When time is used to document, practitio-ners will document the medical necessity of the visit and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary,” according to CMS.1

Another key focus centers on E/M outpatient visits levels 2 through 4. Under the new guidelines, medical practice staff would do the following for levels 2 through 4 visits1:

• Charge patients a single payment rate, with level 5 visits maintaining their unique rate to better account for complex patient care.

• Implement add-on codes for additional resources needed in primary care and some nonprocedural specialized medical care, generally not affecting per-visit documentation requirements.

• Use an add-on code for extended visits to account for the additional resources required when practitio-ners must spend additional time with the patient.

• Meet a standard of minimum supporting documentation associ-ated with a level 2 visit for history, examinations, and medical

decision-making.

Policy problemsThe AMA and other medical groups have

raised some objections to aspects of the proposed policy updates to E/M

outpatient policy. In August 2018, the AMA and approximately 170

national and state medical orga-nizations expressed their formal

opposition to the proposal to collapse payment rates for

eight office visit services down to two for new and

enter the review of system information,”

says Terry A. Fletcher, BS, CPC, CCC, a

health care consultant and coding expert

based in Laguna Beach, California. “Now,

the doctor doesn’t have to repeat some

of the [history of present illness] ele-

ments as long as they are already in the

documentation. Physicians just have to

give evidence that they’ve reviewed the

previous information or updated it.”

Changes coming soonMany of the proposed changes for E/M

outpatient care are still being finalized.

The new guidelines will largely impact

possible revisions to Medicare cod-

ing and payment policy, as well as

further documentation changes.

As described in the CMS

fact sheet titled “Final Policy,

Payment, and Quality

Provisions Changes to the

Medicare Physician Fee

Schedule for Calendar

Year 2019,” methods

of documentation

would be given

more flexibility.1

While practi-

tioners could

continue to

apply the

current

1995

Changes to virtual careIn order to better recognize new technol-ogy and innovations in health care, CMS aims to “increase access for Medicare beneficiaries to these services that are routinely furnished via communication technology by clearly recognizing a dis-crete set of services that are defined by and inherently involve the use of com-munication technology.”14

New policies are being finalized that will increase patient access to cer-tain services14:

• Virtual check-ins (assessments that take place via communication technology)

• Remote evaluation of photos or vid-eos submitted by patients

• Prolonged preventative services available through Medicare tele-health services

Additionally, CMS plans to implement policies from the Bipartisan Budget Act of 2018 and the SUPPORT (Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment) for Patients and Communities Act. These additions will expand telehealth ser-vices for acute stroke patients, ben-eficiaries receiving home dialysis, and patients needing treatment for sub-stance abuse disorders.14

Services shake-up


established patients.10 In its letter to CMS, the AMA and other signatories expressed their belief that such a move would jeop-ardize patient access to care as a result of changes in reimbursement that they consider especially harmful to medical practices that treat the sickest patients.10

“The pushback on some of these poli-cies was significant,” reports Gelburd. “[Although], when CMS said it was look-ing at simplifying documentation and reducing burden, this was welcomed by the provider community. But CMS … coupled that effort to reduce burden with a proposal to collapse payment rates. We certainly want decreased documentation requirements, but why does that policy need to be coupled with the collapsing of payment rates? In our view, the docu-mentation burden doesn’t necessarily need to be associated with payment policy. Consequently, we’ve suggested that CMS go back to the drawing board and not move forward with the payment rate collapse.”

Gelburd offers some additional insight into the disputed issues concerning the original CMS policy proposal: “First, the CMS proposal would have retained level 1, which is the very simple visit. CMS then proposed to blend the payment rate for levels 2 through 5. Thus, a provider could continue to bill for a level 4 visit, for example, with the CPT code associ-ated with that visit but would receive the same payment rate as if they had billed a level 2. What we learned in speaking with [Medical Group Management Association] members is that this blended payment rate would disadvantage practices that treat more complex patients. Any visit that would take an hour and is with a patient [who requires complex care], you’re now being paid the same as if it were a not-so-complex visit, as if it were a level 2 … whereas before you might have received reimbursement for that extra time. That seems very problematic to us.

“As of now, what will take effect in 2021 will be a blending of levels 2 through 4, with CMS retaining level 5,” summarizes Gelburd. “This is a slight revision and a

modest improvement from what was origi-nally proposed, but it’s still using the same policy of blending the payment rate, which we don’t view as a favorable policy.”

Due to the widespread objections to the CMS proposal, Gelburd expects the final policy will see further refinement. “Overall, I think it’s a positive step that CMS delayed these changes until 2021 and is using that delay to continue the dialogue with stakeholder groups and further refine the policies,” she concludes. “Our hope is that they will come up with something that will work better once these more significant updates do take place.”

In response to the provider com-munity’s feedback on Medicare policy, CMS has asked the AMA CPT Advisory Committee for updated coding system recommendations, Gelburd reports. The AMA has already posted some recent changes to E/M codes, which cover non-Medicare-related medical services. These appear in the “CPT Editorial Summary of Panel Actions February 2019”11 and are effective as of January 1, 2021. While additional changes may be forthcoming, the E/M coding changes are reportedly not as extensive as the original proposed Medicare E/M changes.9 For example, the 2021 CPT codebook will exclude code 99201, which covers the simplest type of new patient visit.9

As the nation’s largest payer for health care,12 CMS—particularly Medicare—often sets the standard for the documentation, coding, and payment policies followed by the commercial insurance industry. But this is not always the case. In instances in which the AMA’s CPT coding system is not aligned with Medicare, the latter may create Healthcare Common Procedure Coding System (HCPCS) rules to guide providers with Medicare contracts.

“Every payer has their own billing requirements,” observes David J. Zetter, founder and lead consultant of Zetter Healthcare in Mechanicsburg, Pennsylvania. “While most will follow Medicare’s lead, they can delineate their own rules or require even more. Thus, what’s important

to communicate now is that the AMA is

also making changes to the CPT coding

system. Now, the challenge will be, what is

Medicare going to do with this information?

Medicare does not have to follow what the

AMA does. But CMS will review what the

AMA is putting into place with the CPT

system and decide whether they’re going

to latch onto that or whether they’re going

to make other changes. But as it currently

stands, we still don’t know what Medicare

will require in this regard in 2021.”

Zetter, a member of the National

Society of Certified Healthcare Business

Consultants, cites past actions of CMS

to comment on future coding changes:

“Several years ago, CMS decided it was

going to get rid of consultation codes. No

other payers have done this. Even though

you can now no longer submit ‘consults’

to Medicare, you can with every other

payer. Now the AMA has decided [code]

99201 is going away effective January

2021. There’s also going to be a revision

to all the other E/M codes. [The AMA is]

removing ‘history’ and ‘examination’ as

key components for selecting the level of

E/M service but adding the requirement

that the medically appropriate history

and/or examination must be performed.

This is to report codes 99202 through

Keep the change Although the process is ongoing and debate continues, CMS maintains that documentation guidelines must undergo revision. The motivation for these changes stems from issues with current guidelines14:

• Outdated and falling behind modern technologies

• Unreflective of the complexity of patient care

• Redundant

• Ineffective at accounting for changes in care delivery


Keep the change

99205 and 99211 through 99215. [The

AMA is] also requiring that code selection

be based either on the level of medical

decision-making performed or the total

time spent performing the service on the

day of the encounter. Everyone needs to

be aware of these changes.”

Consequently, in keeping up with the

CMS documentation, coding, and payment

policy updates for outpatient E/M services,

Zetter also encourages medical practices to

review CPT Editorial Summary of Panel

Actions, which are published online by

the AMA. “Everything will eventually be

explained there about what is going to

be changed in the CPT coding book as

of January 2021,” he states.

Documentation development Tellingly, the original 2018 CMS

document detailing the proposed

policy changes for Medicare’s E/M

outpatient services for new and

established patients reportedly

nears some 2,400 pages.13 There

is perhaps some unintended irony

in this fact, considering the docu-

ment’s stated intent to address the

challenge of reducing Medicare

documentation burdens.

Indeed, the Medicare system has evolved into a complex administrative presence over its more than 50 years of existence. For Stella Gallop, CMA-AC (AAMA), a now retired medical assistant who worked many years with a surgical practice, the changes from the system’s early days are profound. “In 1966, Medicare was created, and a year later I started working in health care for a physician prac-tice,” says Gallop. “The Medicare program was so simple then. Basically, you sent in a claim, and they sent


New in 2019Broad support was announced by CMS for the following optional changes to documentation standards14:

• Documentation that states when a home visit is recommended over an office visit is no longer required.

• Instead of reentering data already present in a patient’s record, a physi-cian may instead simply indicate that they have confirmed the information already provided by other staff.

• Physicians may focus documenta-tion on updating information rather than reentering it.

New in 2019


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/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.

Reviewed August 2017. Accessed August 22, 2019.

8. CPT purpose and mission. American Medical

Association. https://www.ama-assn.org/about/cpt

-editorial-panel/cpt-purpose-mission. Accessed

June 10, 2019.

9. Dowling R. AMA announces evaluation and man-

agement coding changes. Med Econ. 2019;96(10).

https://www.medicaleconomics.com/news/ama

-announces-evaluation-and-management-coding

-changes. Published May 16, 2019. Accessed June

1, 2019.

10. 170 groups send letter on proposed changes to

physician payment rule [press release]. American

Medical Association. https://www.ama-assn.org

/press-center/press-releases/170-groups-send

-letter-proposed-changes-physician-payment-rule.

Published August 27, 2018. Accessed June 15, 2019.

11. American Medical Association. CPT editorial sum-

mary of panel actions February 2019. https://www

.ama-assn.org/system/files/2019-03/february

-2019-summary-panel-actions_0.pdf. Updated

March 15, 2019. Accessed August 22, 2019.

12. Centers for Medicare & Medicaid Services. CMS

roadmaps overview. https://www.cms.gov/Medicare

/Quality-Initiatives-Patient-Assessment

-Instruments/QualityInitiativesGenInfo/Downloads

/RoadmapOverview_OEA_1-16.pdf. Accessed

August 22, 2019.

13. Robeznieks A. CMS moves on E/M: three things

physicians should know. American Medical

Association. https://www.ama-assn.org/practice

-management/medicare/cms-moves-em-3-things

-physicians-should-know. Published November 5,

2018. Accessed August 22, 2019.

14. Centers for Medicare & Medicaid Services.

Calendar year (CY) 2019 Medicare physician

fee schedule (PFS) final rule: Documentation

and payment for evaluation and manage-

ment (E/M) visits, advancing virtual

care, and quality payment program.

https://www.cms.gov/About-CMS

/Story-Page/CY-19-PFS-Final

-Rule-PPT.pdf. Accessed

August 22,

2019.

you back your money. That was really about it. There wasn’t much coding at the start, which I learned as the system grew. Of course, gradually it has become so much more complicated.”

A member of the North Carolina Society of Medical Assistants since 1979, Gallop emphasizes how Medicare’s evolving com-plexity only reinforced for her the value of paying attention to office fundamentals. “I can’t say more strongly how important docu-mentation is, particularly when you’re filing claims,” she says. “Because if you don’t code it right, it isn’t going to get paid right. In this sense, I think it’s very important for managers to keep up with the current Medicare rules and guidelines for documentation. It might sound obvious, but it’s worth repeating.”

But more than just dotting i’s and cross-ing t’s, ensuring documentation responsi-bilities are successfully met is also about guaranteeing patients get the quality care they deserve, concludes Gallop. “The patients should always come first. We have to remem-ber this. Medicine is very important to all our lives. As patients, we all want the people who are treating us to do so to the very best of their ability. We don’t want to be rushed through our appointments; we like to be addressed in a friendly way and for the staff to tell us their names. The first thing is to do your job competently and to the best of your ability, as you’re trained to do. Professionalism is very important.”

Hopefully, as Medicare’s Patients Over Paperwork initiative moves forward, the final revisions to the original policy proposals will reflect the constructive input of physi-cians and other providers, toward the goal of promoting a fair, effi-

cient, and improved system for E/M outpa-tient documentation, coding, and payment. The system’s ability to meet these challenges will ensure that the professionalism of the entire health care team is allowed to flourish and that quality patient care remains at the heart of the Medicare mission. ✦

References1. Final policy, payment, and quality provisions

changes to the Medicare physician fee schedule for calendar year 2019. Centers for Medicare & Medicaid Services. https://www.cms.gov /newsroom/fact-sheets/final-policy-payment-and -quality-provisions-changes-medicare-physician -fee-schedule-calendar-year. Published November 1, 2018. Accessed June 1, 2019.

2. Patients over paperwork. Centers for Medicare & Medicaid Services. https://www.cms.gov/About -CMS/story-page/patients-over-paperwork.html. Accessed June 1, 2019.

3. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties [published online September 6, 2016]. Ann Intern Med. 2016;165(11):753-760. doi:10.7326/M16-0961

4. Erickson SM, Rockwern, B, Koltov M, McLean RM. Putting patients first by reducing administra-tive tasks in health care: a position paper of the American College of Physicians [published online March 28, 2017]. Ann Intern Med. 2016;166(9):659 -661. doi:10.7326/M16-2697

5. Finnegan J. Doctors speak out: CMS gets 15,314 comments on proposed physician Medicare chang-es. Fierce Healthcare. https://www.fiercehealthcare .com/practices/doctors-speak-out-cms-gets -15-314-comments-proposed-physician-medicare -changes. Published September 11, 2018. Accessed June 1, 2019.

6. Centers for Medicare & Medicaid Services. Calendar year (CY) 2019 Medicare physician fee schedule (PFS) proposed rule: Documentation requirements and payment for evaluation and management (E/M) visits and advancing virtual care. https://www.cms.gov/About-CMS/Story-Page/2019 -Medicare-PFS-proposed-rule-slides.pdf. Published July 27, 2018. Accessed June 5, 2019.

7. US Department of Health and Human Services; Centers for Medicare & Medicaid Services.

Evaluation and management services. https://www .cms.gov/Outreach-and-Education

/Medicare-Learning-Network-MLN /MLNProducts


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