Physician groups call for CMS to drop E/M proposal


More than 170 physician groups are calling on the Centers for Medicare & Medicaid Services to withdraw a provision in the proposed 2019 physician fee schedule that would flatten evaluation and management payments.


The controversial proposal would set the payment rate for a level 1 evaluation and management (E/M) office visit for a new patient at $44, down from the $45 using the current methodology. Payment for levels 2-5 would be $135. Currently, payments for level 2 new patient visits are set at $76, level 3 at $110, level 4 at $167, and level 5 at $211.

For E/M office visits with established patients, the proposed rate would be $24 for level 1, up from the current payment of $22. Payment for levels 2-5 would be $93. Under the current methodology, payments for established patient level 2 visits are set at $45, level 3 at $74, level 4 at $109, and level 5 at $148.

In an Aug. 28 letter to the CMS, led by the American College of Rheumatology, physician groups applauded CMS recognition of the problems with the current E/M documentation guidelines and codes, but urged them to reconsider plans to “cut and consolidate evaluation and management services.” Doing so would “severely reduce Medicare patients’ access to care by cutting payments for complex office visits, adversely affecting the care and treatment of patients with complex conditions, and potentially exacerbate physician workforce shortages.”

A separate letter, led by the American Medical Association, made similar assertions that the current proposal has the potential to “hurt physicians and other health care professionals in specialties that treat the sickest patients, as well as those who provide comprehensive primary care, ultimately jeopardizing patients’ access to care.”

The American Gastroenterological Association sigend on to both letters.

AGA, along with the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy, sent out a member alert, asking their members to tell CMS not to move forward with the proposed change because all three societies believe that such a payment system undervalues care provided to their sickest and most vulnerable seniors and other Medicare beneficiaries.

Another concern related to the implementation of this proposal is the financial impact on physicians.

Dr. Barbara Levy, vice president of health policy at the American College of Obstetricians and Gynecologists.

Dr. Barbara Levy

Implementation of the CMS proposal, as currently written, “would be amazingly expensive for private practice [doctors] and really for anyone else because we would have to change our EMRs,” Barbara Levy, MD, cochair of the CPT/RUC Work Group at the AMA.

“We would have to reprogram our billing software. All of that comes with a significant cost,” said Dr. Levy, who also serves as vice president of health policy at the American College of Obstetricians and Gynecologists.

Part of the selling point of the CMS proposal is the reduction in documentation that accompanies the E/M payment changes. The goal, according to the CMS, is to reduce time spent on paperwork and free up physicians to devote more time to patient care. But some physicians are skeptical it would work out that way.

"CMS has clearly heard from physicians about the need to reduce administrative burdens for physicians, and AGA appreciates that they're listening," said Peter S. Margolis, MD, AGAF, AGA Practice Councillor, University Gastroenterology, Providence, Rhode Island. "However, CMS' proposal drastically undervalues the care gastroenterologists and hepatologists provide to complex patients, including but not limited to those with inflammatory bowel disease, motility disorders, and chronic liver disease. Additionally, our experience shows that utilization management methods, such as prior authorization and step therapy appeals, are far more burdensome to physicians and physician practices than current E/M documentation requirements."

Another element of the proposal that is raising concerns among physician groups is a proposed payment reduction when a visit involves more than one service. For example, when a single office visit includes both an E/M code and a procedure code, the proposal calls for the E/M code to be cut in half.

“From the patients’ perspective, the potential threat is that doctors could be incentivized to spend less time with patients or potentially bring patients back for subsequent visits to handle multiple problems,” Angus Worthing, MD, chair of the American College of Rheumatology’s Committee on Government Affairs, said in an interview.

Comments on the proposed update to the 2019 Medicare physician fee schedule are due Sept. 10.


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