Medicare final rule: How E/M changes help urologists

Ray Painter, MD

Mark Painter

The Medicare Physician Fee Schedule final rule is out. Medicare has not adopted all of the proposed changes for 2019 that were discussed in our August column (“Medicare proposed rule outlines significant changes"). However, the final rule does include a timeline that will implement many of the changes recommended by 2021 with some revisions. Below, we will address a few of the most notable inclusions in the final rule for 2019 and touch on preparation that will need to be undertaken for 2021. (To view the rule in its entirety, go to bit.ly/2019finalrule.)

Evaluation/management

The Centers for Medicare & Medicaid Services (CMS) has delayed the proposed major changes to E/M documentation and payment until 2021, which we will discuss later in this article. Here, we will focus on relevant CMS changes for E/M coding for 2019 and 2020.

First, CMS has removed the requirement that justification of a home visit in lieu of an office-based visit is documented in the medical record. Second, CMS has finalized a policy to simplify history and exam for established patients. For 2019 and 2020, 1995 and 1997 guidelines remain as the framework for documentation of all E/M visits. The changes pertain to how these requirements are met.

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It appears that although CMS lists exam as part of the simplification as a general rule for the established patient, this simplification seems to indicate that the provider will not have to reenter any exam entered by staff, and document that the information was reviewed for the visit. The requirements remain as listed in the 1995 and 1997 guidelines. With regard to documentation of history, we note the following from the final rule:

• “We proposed to expand this policy to further simplify the documentation of history and exam for established patients such that, for both of these key components, 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. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.”

• “For new and established patients for E/M office/outpatient visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.”

• “We note that this policy to simplify and reduce redundancy in documentation is optional for practitioners, and they may choose to continue the current process of entering, re-entering and bringing forward information.”

In summary, the changes to outpatient E/M documentation in the office for 2019 and 2020 are:

• History of Present Illness (HPI) can be documented by patient or staff and reviewed by provider. Specifically stating that physicians do not have to personally document the HPI will be very beneficial. There has been some confusion on this issue, with some compliance departments requiring that the billing provider must document the entire HPI, while others suggested that staff could collect HPI but the provider must finalize and “own” the HPI.

• Review of Systems (ROS) and Past Family and Social History (PFSH) that have previously been documented in the chart can be reviewed and updated without re-documenting all elements.

Reviewing and updating previously collected ROS and PFSH has been allowed with the 1995 and ’97 guidelines.

However, of interest is that they did not mention having to document the date of the previous documentation, as required in the previous guidelines. This will simplify the documentation process.

• Physical exam that has been documented in the medical record can be reviewed by the physician.

The ability of the physician to review PE for established patient information will be limited for urologists as PE is rarely a limiting factor for established patients. Remember: Only two out of three key components are required for established patient visits. 

We note that CMS reiterated that focus on new or relevant existing information that is medically relevant should be confirmed or further documented by the physician.

In short, the focus of the reviews under these revised rules will continue to be on medical necessity of the information documented and the services rendered for each visit. As we have taught in the past, medical necessity must be the driver of appropriate E/M level selection and appropriate documentation protocols. Simple copy and paste without review and documentation of a medically appropriate update will likely remain a target of any chart reviews.

Next:Telemedicine codes

Telemedicine codes

Virtual check-in code. CMS is adding a new code and coverage for a virtual check-in. This service would be billable when a physician or other qualified health care professional has a brief nonface-to-face check-in with a patient via communication technology, to assess whether the patient’s condition necessitates an office visit. Unlike other services Medicare pays for under telehealth rules, the virtual check-in visit can be provided via phone only or via audio and visual technology.

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G2012 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion) can only be reported if the service is provided by a physician or advanced practice provider.

As noted in the description, this service can only be provided to established patients. Medicare has elected not to include any frequency limitations at this time, but as with all Medicare services, the virtual check-in visit must be medically necessary. As the description indicates, if the virtual check-in visit is within 7 days of an E/M visit or the virtual check-in leads to an E/M visit in the near future, the virtual check-in visit will be considered bundled into the E/M visit before or after the virtual check-in visit.

Finally, as the patient will be responsible for co-payment with the visit, the patient must consent to the service. Consent can be verbal or written. We recommend that written forms be obtained from the patient when in the office and included in the medical record. This form could be a blanket form that informs patients that the check-in service is available and covered but will have an associated co-payment. However, Medicare is expecting that the patient will initiate the majority of these visits and in lieu of a signed consent for a virtual visit, inclusion of the verbal approval in the patient record as proof of verbal agreement will be acceptable.

We can see a number of applications for this code in urology. CMS is seeking comment on appropriate parameters to prevent overuse and abuse of this service and will be closely monitoring the utilization of this code.

Remote evaluation of video or images from patient. Medicare has added code G2010 (Remote evaluation of recorded video and/or images submitted by an established patient [e.g., store and forward], including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment).

Similar to the virtual check-in code above, the service is limited to established patients and cannot be preceded by an E/M visit in the last 7 days or lead to an E/M visit in the near future. Also, as with check-in visits, the service must be medically necessary and written or verbal consent must be documented as the patient will have partial responsibility for payment.

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Medicare has expanded the response method for code G2010 to include not only telephone and audio-visual follow-up for received image and/or video but will also allow follow-up through HIPAA-compliant texting, email, and/or patient portal communication. Medicare will be carefully monitoring utilization of this new code.

Next:Global period dataGlobal period data

CMS will be reminding physicians in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island in practices with 10 or more physicians that they are to report postoperative visits for 209 different procedures. Urology has not participated very well in this program. Remember that failing to report post-op visits as requested may result in lower payments for these services in the long run.

Impact of relative value unit changes on urology

There were a number of changes to RVUs for 2019, both positive and negative. The impact of all the changes is projected to be favorable for urology, with a positive 4% impact on the overall income for urologists. We encourage you to review your fee schedules for 2019, as some of these changes may impact your contracted rates in addition to your Medicare fees.

Also see: Why your practice needs to track phone call quality

Unfortunately, we do not have room in this article to list all changes. AUAcodingtoday.com and Medicare fee schedule look-up tools will be updated prior to Jan. 1, 2019 to allow offices to review and adjust fees and expected reimbursements.

Looking ahead to 2021

There were some significant modifications to the proposed rules and the adopted rules to be implemented in 2021. The most important change was the decision not to reduce payment when E/M office/outpatient visits are furnished on the same day as procedures. CMS left the door open for additional comments and changes to be adopted later.

The major changes for 2021 E/M codes are as follows:

• paying a single rate for E/M office/outpatient visit levels 2, 3, and 4 with a minimum documentation requirement meeting a level 2 visit

• E/M office/outpatient levels 1 and 5 visits will continue to have unique payment levels

• adoption of new add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of specialized medical care (includes urology) for use with levels 2-4 only

• adoption of a new “extended-visit” add-on code for use only with E/M office/outpatient level 2 through 4 visits

• flexibility in how visit levels are documented, specifically a choice to use the current “level 2” framework (as discussed above), medical decision-making only, or time

• elimination of the requirement for counseling or coordinating care to charge based on time.

Stay tuned; 2021 is barely over 2 years away.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.