President Donald L. Fordham, MD submitted a letter of comment on behalf of the Georgia Academy on the proposed revisions to the 2020 physician fee schedule for Medicare. These comments echoed many of the points that the AAFP submitted to the Centers for Medicare & Medicaid Services (CMS). Below are some of the highlights of those comments:
The Georgia Academy respectfully offers comments on the following high-level issues for your consideration.
Office/Outpatient Evaluation and Management (E/M) Coding. The Georgia Academy supports the adoption of the work relative value units (RVUs) recommended by the RVU Update Committee (RUC) for all the office/outpatient E/M codes, the new prolonged services add-on code, and CMS’ proposal to maintain separate values for levels two through four visits rather than implement its plan for a blended payment rate for those services. However, since most family medicine practices already operate on extremely thin margins and these services have been undervalued for decades, we implore CMS to implement these changes in 2020 rather than 2021 as proposed.
Global Surgical Packages. Based upon analysis available from RAND and the Medicare Payment Advisory Commission, we believe the proposed recommendations put forth by CMS are the appropriate policy. Therefore, we strongly support CMS’ proposal to not adjust the office/outpatient E/M visits for codes with a global period to reflect the changes made to the values for office/outpatient E/M visits.
Chronic Care Management. The Georgia Academy is concerned the addition of new principal care management (PCM) codes would move away from the continuous, comprehensive, and coordinated value-based care and primary care CMS has otherwise been encouraging as a cost-effective way to care for Medicare patients. We offer alternative recommendations in the body of the letter to strengthen care for beneficiaries with chronic conditions and urge CMS to use the existing Current Procedural Terminology (CPT) coding process to make changes to these codes.
II.J. Review and Verification of Medical Record Documentation
Building on medical record documentation relief it implemented in 2019, CMS proposes to establish a general principle to allow the physician, the physician assistant (PA), or the advanced practice registered nurse (APRN) who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students, or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the physician fee schedule. Because this proposal is intended to apply broadly, CMS proposes to amend regulations for teaching physicians, physicians, PAs, and APRNs to add this new flexibility for medical record documentation requirements for professional services furnished by teaching physicians, physicians, PAs, and APRNs in all settings.
Specifically, CMS proposes to amend relevant sections of its regulations to add a new paragraph entitled, “Medical record documentation.” This paragraph would specify that, when furnishing their professional services, the clinician may review and verify (sign/date) notes in a patient’s medical record made by other physicians, residents, nurses, students, or other members of the medical team, including notes documenting the practitioner’s presence and participation in the services, rather than fully re-documenting the information. CMS notes that, while the proposed change addresses who may document services in the medical record, subject to review and verification by the furnishing and billing clinician, it does not modify the scope of, or standards for, the documentation that is needed in the medical record to demonstrate medical necessity of services, or otherwise for purposes of appropriate medical recordkeeping.
CMS also proposes to make conforming amendments to its regulations to also allow physicians, residents, nurses, students, or other members of the medical team to enter information in the medical record that can then be reviewed and verified by a teaching physician without the need for re-documentation.
Georgia Academy of Family Physicians Response
The Georgia Academy strongly supports CMS’ proposals in this regard as it is long overdue. The proposed principle and related regulatory changes are consistent with prior CMS efforts to reduce the administrative burden associated with medical record documentation. They are also consistent with the team-based model of care used in family medicine practices and residencies. However, we urge CMS to clarify that multiple students and residents can enter patient information into the medical record even on the same day and during the same office visit. We encourage CMS to finalize this proposal as clarified per our recommendation in the final rule this fall.
- P. Payment for Evaluation and Management (E/M) Visits
Summary – Office/Outpatient E/M Visit Coding and Documentation
For calendar year 2021, for office/outpatient E/M visits (CPT codes 99201-99215), CMS proposes to adopt the new coding, prefatory language, and interpretive guidance framework adopted by the CPT Editorial Panel for CPT 2021. This includes deletion of code 99201 and acceptance of a new, single add-on CPT code for prolonged office/outpatient E/M visits (code 99XXX) that would only be reported when time is used for code-level selection and the time for a level five office/outpatient visit (the floor of the level five time range) is exceeded by 15 minutes or more on the date of service. This new add-on code would obviate the need for code GPRO1 (extended office/outpatient E/M time), which CMS had planned to implement in 2021, but now proposes to delete instead.
The one variance from CPT in this regard is that, for Medicare, CPT codes 99358 and 99359 (Prolonged E/M without direct patient contact) would no longer be reportable in association or “conjunction” with office/outpatient E/M visits. New CPT prefatory language specifies 99358 and 99359 may be reported for prolonged services on a date other than the date of a face-to-face encounter. CMS believes its proposed policy regarding 99358 and 99359 would be consistent with the way the office/outpatient E/M visit codes were resurveyed, where the RUC instructed those surveyed to consider all time spent three days prior to, or seven days after, the office/outpatient E/M visit. CMS finds the CPT language and reporting instructions related to 99358 and 99359 to be unclear and circular and believes CPT codes 99358 and 99359 may need to be redefined, resurveyed, and revalued. In the meantime, CMS seeks public input on its proposal and whether it would be appropriate to interpret the CPT reporting instructions for CPT codes 99358 and 99359 as proposed, as well as how this interpretation may impact valuation.
Georgia Academy of Family Physicians Response – Office/Outpatient E/M Visit Coding and Documentation
The Georgia Academy appreciates and strongly supports CMS’ proposal to adopt the new coding, prefatory language, and interpretive guidance framework adopted by the CPT Editorial Panel for CPT 2021. This includes deletion of code 99201 and acceptance of a new, single add-on CPT code for prolonged office/outpatient E/M visits (code 99XXX) in lieu of the code (GPRO1) CMS previously planned to use.
Changes of this magnitude may have an impact on EHRs, since most are built around the current CPT structure and 1995/1997 E/M documentation guidelines. If CMS finalizes this proposal, it must provide this updated framework to EHR vendors as soon as possible and work with the American Medical Association (AMA) and specialty societies on the physician communications and educational efforts that will be needed between now and 2021.
Regarding codes 99358 and 99359 (Prolonged E/M without direct patient contact), we acknowledge the points of confusion in the CPT guidance for use of these codes in conjunction with office/outpatient visit codes vis-à-vis the parameters in which the latter codes were surveyed for the RUC. However, we would encourage CMS to work with the CPT Editorial Panel to resolve these points of confusion between now and 2021 rather than unilaterally making 99358 and 99359 no longer reportable in conjunction with office/outpatient E/M visits for Medicare.
Part of the administrative complexity and burden that hampers our members’ ability to care for their patients is variability in payment policy among payers and payment policy at odds with guidance otherwise included in CPT. CMS’ proposal to unilaterally change its payment policy in this regard, and in conflict with CPT would add to our members’ administrative complexity and burden. Therefore, we oppose CMS’ proposal and instead urge CMS to work through the CPT process so any changes apply to more than just Medicare. As noted in the AAFP’s policy on “Coding and Payment,” the AAFP supports CPT and the coding principles it contains. Thus, the Georgia Academy believes it is important for both physicians and health plans to abide by the principles of CPT.
Summary – Office/Outpatient E/M Visit Revaluation (CPT codes 99201 through 99215)
CMS proposes to adopt the RUC-recommended work RVUs for all the office/outpatient E/M codes and the new prolonged services add-on code, effective for dates of service on or after January 1, 2021. CMS proposes to maintain separate values for levels two through four visits rather than implement its plan for a blended rate for those services.
Regarding the RUC recommendations for PE inputs for these codes, CMS proposes to remove equipment item ED021 (computer, desktop with monitor), as CMS does not believe that this item would be allocated to the use of an individual patient for an individual service. Instead, CMS believes this item is better characterized as part of indirect costs like office rent or administrative expenses.
The one point of confusion or concern for CMS in valuing these codes concerns the total physician time to be assigned to each code. As CMS notes, the RUC separately averaged the survey results for pre-service, day of service, and post-service times, and the survey results for total time, with the result that, for some of the codes, the sum of the average times associated with the three service periods does not match the RUC-recommended total time, which was the average of the respondents’ total time. A simple example illustrates how this might occur:
CMS is concerned by the fact that if one adds up the medians of the individual time components (which is 5 [2+2+1] in the illustration above), the total does not equal the median of total time among all respondents (which is 4 in this illustration).
CMS proposes to adopt the RUC-recommended times, in which total time reflects the median of total time among all respondents rather than the sum of the medians for the three components of total time. However, CMS seeks comment on how it should address the discrepancies in median total times versus sum of the median component times. CMS believes this has implications both for valuation of individual codes and for MPFS rate setting in general, as the intra-service times and total times are used as references for valuing many other services under the MPFS and the programming used for MPFS rate setting requires that the component times sum to the total time. Specifically, CMS requests comment on which times it should use, and how it should resolve differences between the sum of the components and median total times when they conflict.
Georgia Academy of Family Physicians Response- Office/Outpatient E/M Visit Revaluation (CPT codes 99201 through 99215)
The Georgia Academy appreciates and strongly supports CMS’ proposal to adopt the RUC-recommended work RVUs for all the office/outpatient E/M codes and the new prolonged services add-on code, effective for dates of service on or after January 1, 2021. However, since most family medicine practices already operate on extremely thin margins and these services have been undervalued for decades, we implore CMS to implement these changes in 2020. We also appreciate and support the CMS proposal to maintain separate values and payment for levels two through four visits rather than implement its plan for a blended rate for those services.
However, we respectfully disagree with the CMS proposal to remove equipment item ED021 (computer, desktop with monitor) from the direct PE inputs for these codes. According to the Centers for Disease Control and Prevention (CDC), 85.9% of office-based physicians are using an EHR. Medication and problem lists must be accurately maintained by physicians during a visit using their EHRs. Furthermore, with the multiple medications now required by many patients, monitoring for drug-drug interactions becomes an essential component for patient safety and quality care. All of this makes a computer a typical, indispensable part of the medical equipment used during an office visit. Whether it’s a desktop computer with monitor or a laptop, some computer is typically being used during an office visit, and contrary to CMS’ belief, is allocated to the use of an individual patient for an individual service, just like the exam table in the room.
There is precedent for including a computer as a direct PE. There are 52 CPT codes that include equipment item ED021. For office visits, the work being performed using the computer is not administrative in nature. Rather, it is used to record, analyze, and communicate to the physician about every element of data that the clinical staff collects from the individual patient for the individual service.
In sum, the computer is dedicated solely to each patient throughout the visit to collect history, share and discuss lab and test results, and document the visit. It is an essential tool in conducting today’s office visits, and CMS should recognize it as a direct medical equipment cost. We encourage CMS to accept the RUC’s recommendation to include item ED021 (computer, desktop with monitor) among the direct PE inputs for these codes.
Georgia Academy of Family Physicians Response – Valuation of CPT Code 99XXX (Prolonged Office/Outpatient E/M)
The Georgia Academy appreciates and strongly supports CMS’ proposal to adopt the RUC-recommended work RVUs for the new prolonged services add-on code, effective for dates of service on or after January 1, 2021. However, since most family medicine practices already operate on extremely thin margins, we implore CMS to implement these changes in 2020.
Summary – Global Surgical Packages
Considering three RAND reports on the subject and CMS’ understanding that work RVUs for procedures with a global period are generally valued using magnitude estimation, CMS does not state its intent to accept the RUC recommendation to adjust the office/outpatient E/M visits for codes with a global period to reflect the changes made to the values for office/outpatient E/M visits. Instead, CMS states it will give the public and stakeholders time to study the RAND reports (which CMS makes available), along with this rule and consider an appropriate approach to revaluing global surgical procedures. CMS will continue to study and consider alternative ways to address the values for these services.
Georgia Academy of Family Physicians Response – Global Surgical Packages
Based upon analysis available from RAND and the Medicare Payment Advisory Commission, we believe the proposed recommendations put forth by CMS are the appropriate policy. Until such time that verifiable, third-party data provides a clearer justification for the inclusion of E/M codes in the global period we strongly support CMS’ decisions as outlined in the proposed rule. As CMS notes in the proposed rule and as the RUC and the surgical specialties have frequently maintained, work RVUs for procedures with a global period are generally valued using magnitude estimation rather than building blocks.
As noted in the proposed rule and as required by law, CMS is collecting data to validate the number and level of E/M services assumed to be included in global surgical services. The RAND study analyzing data collected through claims supports CMS’ intent not to accept the RUC recommendation to adjust the office/outpatient E/M visits for codes with a global period to reflect the changes made to the values for office/outpatient E/M visits. For instance, during the first 12 months of reporting post-operative visits via claims, RAND found most procedures with 10-day global periods did not have an associated post-operative visit. Further, among procedures with 90-day global periods, the ratio of observed-to-expected post-operative visits provided was only 0.39. Further, in its study of the levels of post-procedure visits, RAND found the reported physician time and work for the post-operative visits in the two 90-day global codes studied (i.e., cataract surgery and hip replacement) were generally similar—but slightly less—than the levels expected based on the E/M visits assumed to typically occur by CMS when valuing these procedures
The Office of Inspector General and others have questioned the accuracy of current assumptions underlying 10- and 90-day global codes. Until CMS can adequately address those questions, we believe it would be imprudent to adjust the E/M component because of any changes to the values of stand-alone office/outpatient visit codes 99201-99215 and we strongly support CMS’ decision in this regard. We continue to believe the best approach to this issue is to convert all codes with a 10- or 90-day global period to zero-day global periods and revalue the codes accordingly and thereby allow physicians to appropriately code and document necessary pre- and post-operative services using the E/M codes inclusive of their new values and payment amounts. For decades, physicians using these global codes have not been required to follow the E/M documentation guidelines for charting in the medical record for such visits which has been blatantly unfair to the rest of the physician community and especially primary care—it is time for the global service codes to be eliminated and level the playing field for all physicians and other clinicians.