By skyforbes 
On July 27, 2018, the Centers for Medicare & Medicaid Services (CMS) released a proposed Rule ‘CMS-1693-P’ with an aim to lower the cost of the American Healthcare System. The reformed guidelines modified the documentation timing by using the latest Current Procedural Terminology (CPT) code requirements by the American Medical Association (AMA).
The most imperative refurbishments have been made to the Evaluation and Management (E&M) services as well as telemedicine reimbursement.
Evaluation and management services are used by various healthcare providers for medical coding in support of medical billing. In the healthcare industry, reimbursement by Medicare, Medicaid programs, or private insurance for patient encounters is done by using these guidelines only.
CMS is proposing various changes in the coding and billing process of E/M Guidelines. In the healthcare industry, these guidelines have not been updated since the last 20 years. But preceding July, CMS proposed a dramatic overhaul in the system.
The reformation done will make the payment system in the industry more transparent with an undertaking to make it easier for patients as well as physicians. The recommended implementations by CMS will chiefly update Medical Decision-Making (MDM), Physician Fee Schedule (PFS) and calendar-year 2019 Quality Payment Program (QPP).
Although a two-year window has been given for 2019–20, the proposed final rule has already started to reduce the burden of patients as well as the physician. The aim is to replace the existing 5 tier system into one single uncomplicated payment system and to lower the complex documentation procedure.
Pre-CMS Overhaul And The Reasons Behind The Proposed Refurbishment
For more than two decades, physicians have struggled with unnecessary paperwork and overcomplicated regulatory requirements. With each patient visit, the Evaluation and management documentation process had become a burdensome process for the billers and coders. The necessity of a change in the recording of E/M visits was simmering for a long time in the healthcare industry.
Multiple visits of patients in a day were re-documented which created redundant paperwork and deviated decision-making process of medical practitioners. It was hard for physicians to focus on the patient and give them the proper time they needed.
The Quality Payment Program (QPP) has also faced excessive regulations with minimal technology-based service evaluation. High-Quality patient care was much needed in the virtual care of the patient. Restructuring both Merit-based Incentive Payment System (MIPS) and Average Sales Price (ASP) was required to reduce provider reimbursement rates for new drugs under Medicare.
Post CMS Overhaul
On November 1st of 2018, CMS published the final rule reforming important guidelines followed during EM visits. The 2379 pages overhaul has taken a giant leap forward in the following topics:-
1. Virtual Care
CMS has made a colossal change in the method of “check-ins” with doctors. With the introduction of virtual care, they have made the interaction between doctors and patients less time-taking. The new rule will provide technology-based communication services in exchange of classified videos/images. This will save patients the time to travel and visits doctors’ office. CMS is taking the services to next level by proposing telemedicine services with online payments and communication.
2. 1995 & 1997 Documentation
A long-awaited change also took place in the previous year’s final rule. The Medicare billing of the E/M office and outpatient visits either uses the 1995 or 1997 E/M guidelines documentation. But after the overhaul, regardless of the level of history, physicians could choose the documentation of an E/M visit by time or their decision making authority.
3. Single Payment Rate And System
After the refurbishment, CMS has reduced the payment variation by proposing a single payment rate system. The proposed method includes both new patients’ visits (99202–99205) as well as established patients’ visit (99212–99215). The decision affirms one rate for payment of level one patients and a different payment rate for level 2–5.
The documentation requirements for level 2 will cover the documentation for all the levels from 2 through 5. Unless the time factor is used to document the services, the documentation requirements (history, examination, and medical decision-making) will be the same.
4. Reduction In Redundant Work
From 2021, the rule of two separate billing of E/M visits of a minor procedure scheduled at the same day will be eliminated. E/M payment will be reduced by 50% of the least expensive procedure. This will reduce the revenue of the practitioners, but will benefit patients. CMS is proposing telemedicine services with online payments and communication to alleviate the burden of patients.
5. Introduction of Add-on Codes
In office and outpatient E/M levels 2–4 where a patient requires complex care, the rule has introduced add-on HCPCS Level II codes. This will eliminate the new per visit document requirements in providers’ reimbursement. For complex care patients, a new add-on G code will be billed with the primary code to adjust the additional costs used in level 2–5.
For primary care, the add-on amount would be $5, and for approved specialties above the E&M level 2–5, $14 would be accepted.
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