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2019 Final Medicare Physician Fee Schedule

2019 Final Medicare Physician Fee Schedule November 2, 2018

The Final Physician Fee Schedule was issued yesterday, November 1, 2018.  The biggest question on everyone’s mind was whether we would see massive changes to evaluation and management (E/M) services coding in 2019.  The answer is no.  The final rule indicates the changes to E/M services will be effective on January 1, 2021.  However, CMS did finalize important documentation changes which will be effective January 1, 2019.

E/M Documentation Changes Effective January 1, 2019

  • Providers will no longer be required to re-document relevant history and exam documentation that is already contained in the medical record for established patient visits in the office/outpatient setting.
    • Providers will be allowed to focus their documentation on history and exam items which have changed since the prior visit and on pertinent items that have not changed.
    • The provider will have to specifically document the information which was reviewed and make updates as necessary.
    • This rule does NOT apply to new patients or medical decision making.
  • Providers will no longer be required to re-document information pertaining to the patient’s chief complaint and history entered by ancillary staff or the patient for both new and established patient visits in the office/outpatient setting.
    • Providers will have to specifically document that he/she reviewed and verified the information.
  • Medical record documentation supporting the extent of a teaching physician’s participation in the review and direction of services furnished to a beneficiary may be documented by a physician, resident or nurse.
    • The teaching physician will no longer be required to document the extent of their participation in the review and direction of resident services provided to a patient.
    • The new rule does not apply to primary care exception, dialysis and psychiatry services.

Outpatient office (99201-99205) Documentation, Coding, and Payment Changes Effective January 1, 2021

  • Blended payment rate for levels 2, 3 and 4
    • There will be one payment rate for new patients and a separate payment rate for established patients.
  • Providers will continue to report the level of E/M furnished.
  • Creation of add-on codes reportable with levels 2-4 to reflect complexity in primary care and non-procedural specialty care
    • GPC1X- Visit complexity inherent to E/M associated with primary medical services that serve as the continuing focal point for all needed health care
    • GCG0X- Visit complexity inherent to E/M associated with non-procedural specialty care
  • Creation of add-on codes reportable with levels 2-4 to reflect complexity in time (Time will no longer solely be based on counseling and coordination of care)
    • GPRO1- Established patient requiring direct patient contact of 34-69 total face-to-face minutes
    • GPRO1- New patient requiring direct patient contact of 38-89 total face-to-face minutes
  • Documentation guidelines will be based on current framework (1995 or 1997) or medical decision making (MDM) or
    • For levels 2-4, a minimum documentation standard will apply which mirrors the current documentation requirements for a level 2 visit
    • In each instance, the provider will be required to document the medical necessity of the visit
    • The current levels of MDM associated with E/M will remain unchanged and will apply when billing based on MDM

The Final Rule includes many additional changes.  We recommend you review the Final Rule in its entirety and initiate training, EMR template and CDM revisions to accommodate the upcoming January changes as well as begin preparations for the upcoming 2021 E/M changes.  The HBE team is available to provide assistance with preparing your organization for these significant changes.

The complete Final Rule is at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html

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