SPECIAL COMMENTARY: What is CMS’ True Motive Behind the Dramatic Proposed Changes to the Evaluation & Management Documentation Guidelines and Related Reimbursement Amounts?

Abstract

           All non-invasive services rendered by a health care provider, especially physicians and mid-level providers, are “coded” for billing/reimbursement purposes using a five-digit Evaluation and Management (“E&M”) code based on the Current Procedural Terminology (“CPT”) established by the American Medical Association (AMA). These codes, in place since 1995, are updated annually by the AMA and are tied to actual monetary reimbursement from both Medicare/Medicaid as well as from most commercial insurers.

          During the summer of 2018, the U.S. Centers for Medicare and Medicaid Services (“CMS”) proposed major changes to some of the most common E&M codes that relate to patient visits to various types of physicians’ offices. The number of such codes changed but, of greater consequence, so did the reimbursement amounts, with many specialist physicians slated to incur marked reductions in compensation for their services.  The author, a Certified Professional Coder of longstanding, asserts that the proposed changes are much more than “housekeeping” details, and she validates the concerns of numerous medical specialty associations that the net effect of these proposed changes would be to dis-incentivize large numbers of specialty physicians from treating Medicare and other patients.  In fact, if these proposals are implemented it may no longer make economic sense for many specialty physicians to remain in practice.  Is this the kind of result that the U.S. Government wants?

Editor's Note from James Unland: One of the coordinators of the American Medical Association's letter to the CMS Administrator was Dr. Barbara Levy of the American College of Obstetricians and Gynecologists.  My audio interview with her about these matters runs 7 minutes and can be listened to on the web or downloaded as an MP3 file.  LINK to Interview  

Read the AMA's Letter to the CMS Administrator, Seema Verma