CMS 2019 PFS E&M – single payment coding and 50% reduction with modifier 25 usage

In what is being reported as the biggest change of its kind in more than two decades, the Centers for Medicare & Medicaid Services (CMS) plans to redefine the documentation requirements for evaluation and management (E&M) coding in 2019, along with flattening payments for new and established patient office visits to a single pay system. The proposal offers $93 for established office visit codes (99212-99215) and $135 for new patient visits (99202-99205).

CMS is proposing to forego the 1995 and 1997 guidelines for what is being reported as a “simpler model” that will eliminate the need to re-document redundant information from prior visits and instead focus on medical decision-making. CMS is also proposing to blend patient E&M encounters into one specific relative value unit (RVU) because in their opinion, documentation is based on the ability of providers to get into their electronic medical records (EMRs) to find additional information other than what was noted.

But what is missing in all this is the reality of the reimbursement concerns, especially for specialty physicians who are taking care of sicker patients who need more time, effort, and higher levels of care to manage their complex issues.

This proposal will in effect penalize those physicians in specialties such as oncology (7 percent reduction), neurology (7 percent reduction), cardiology (3 percent reduction), pulmonary (3 percent reduction), rheumatology (7 percent reduction), and nephrology (3 percent reduction), to name a few. This does nothing to cut spending under the Medicare program, but more redistributes money among physicians.

Instead of the American Medical Association (AMA), in conjunction with Medicare, adopting a new code set, CMS is attaching the same RVU to the level 2 through 5 codes for both new and established patients, which creates the same payment amount. Most of the impact will be focused on 99214 and 99215, with a 15 percent cut of about $16-$23. These codes are about 89 percent of all allowed services, according to CMS data, and practices routinely billing the 99204 new patient code would see a 13 percent decrease in reimbursement. Your E&M profile would determine if you are in the “win” or “lose” column with this proposal.

Modifier 25 could be used as a reduction edit for CMS, not protection for your E&M encounters.

Also included in the 2019 proposal is the multiple payment reduction proposal. How many times do you place a modifier 25 on an E&M service when providing a second service (i.e., a skin tag removal, an injection, a diagnostic test, etc.) on the same day? Often done for patient convenience and for physician efficiency, CMS is proposing to reduce reimbursement for such services by half (the national equivalent of $47-$68 on a sick visit encounter). This reduction model previously has only been applied to surgical procedures, when multiple procedures are performed during the same surgical event. The impact of this change on physician office-based and outpatient-based services would be dramatic.

Modifier 25 serves as a true indicator of a:

Significantly, separately identifiable evaluation and management service above and beyond the pre-service workup of a procedure, performed on the same day by the same physician

As such, it should remain untouched to ensure that all Medicare beneficiaries are provided appropriate care and evaluations and are not forced to make repeat visits, resulting in increased co-payments and out-of-pocket costs, not to mention unwarranted, burdensome, and expensive travel back to the office!