CMS Changes to Physician Fee Schedule 2019: What you need to know.

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

According to Phyllis Dobberstein, DocuTAP’s Compliance and Privacy Officer, it’s an important update to the old rules of the game that were established before the adoption of EMR/EHR by the healthcare community—back when all documentation was done on paper.

According the CMS, the 2019 PFS final rule is “one of several final rules that reflect a broader administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.”

In a press release regarding the final rule, CMS stated that the agency believes “these policies will allow practitioners greater flexibility to exercise clinical judgment in documentation, so they can focus on what is clinically relevant and medically necessary for the beneficiary.”

The good news is, these new rules will be rolled out in steps, starting with some minor changes for the 2019 calendar year. Bigger changes have been proposed for 2021 and are under review by the AMA.

2019 – Review, update, verify

One of the biggest changes to the 2019 final rule changes the requirements for documenting a patient’s chief complaint (CC) or any part of the history (HPI), past family social history (PFSH) or review of systems (ROS) for new and established office/outpatient E/M visits.

Starting in 2019, for established patient office/outpatient visits, when relevant information is 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 re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.

For new and established patients, any part of the chief complaint (CC) or history can be documented in the medical record by ancillary staff or the beneficiary.  Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so. While this change is optional, it is broadly supported, state laws regarding scope of practice will determine which ancillary staff are approved to provide the initial documentation for approval by the billing practitioner.

One other benefit of this new rule isn’t nearly so easy to quantify. Removing the requirement to re-document can reduce the frustration of doctors concerned with spending too much time on paperwork and not enough time connecting with their patients.

While not nearly as relevant to urgent care, there are additional changes regarding virtual care. To prevent unnecessary office visits, CMS recognizes virtual check-in by phone or other electronic devices, and review of patient-transmitted images with “store and forward” video or imaging technology. Neither is reimbursable if the patient is seen seven days prior to or 24 hours after the virtual communication.

While changes to the current coding and payment structure for E/M office/outpatient visits are expected in 2021, clinics should continue to use either the 1995 or 1997 E/M documentation guidelines to document visits.

2021 – Fewer E/M codes to reduce administrative burden

Beginning in 2021, CMS is expected to implement payment, coding, and other documentation changes to further reduce billing and documentation complexities.

The AMA is reviewing a proposed reduction in payment variation for E/M visit levels with a single rate for visit levels two through four for established and new patients, but maintaining the payment rate for visit level five to reflect the care of complex patients.

In addition, CMS will allow more flexibility in how visits (levels two through four) are documented, giving billing practitioners a choice to use the current framework, medical decision-making (MDM), or time a practitioner spent face-to-face with a beneficiary. When using time, medical necessity must be documented.

Although a lot depends on the AMA, other changes to the coding requirements are also expected to take effect in 2021.

Implications for urgent care

“For urgent care clinics, simplified coding and reduced documentation requirements will allow doctors to spend more time with patients,” said Dobberstein. “And it will also lower compliance risks.”

Overall, this final rule and expected changes should simplify the documentation process, which is good for urgent care.

Dobberstein would like to see the urgent care industry have a bigger role in future regulation and rulemaking because of its growing impact on the entire healthcare marketplace. “Urgent care is growing because it responds to what today’s consumers want. This industry paves the way for unprecedented advances in healthcare that improve the patient experience and provide increased access to healthcare through innovation.”

Read the full CMS press release here.

This resource was first published prior to the 2019 merger between DocuTAP and Practice Velocity. The content reflects our legacy brands.