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CMS proposal to level E/M payments raises concerns


Citing the need to reduce paperwork hassles, officials at the Centers for Medicare & Medicaid Services are proposing to flatten the payment for evaluation and management (E/M) visits coded at levels 2-5.

The CMS outlined how the proposal would affect payment using 2018 rates to model the change. The proposal would set the payment rate for level 1 E/M office visits for new patients at $44, down from the $45 using the current methodology. Levels 2-5 would receive $135. Currently, payments for level 2 visits are set at $76, level 3 at $110, level 4 at $167, and level 5 at $211.

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

The change also comes with a reduced documentation burden, so the same documentation is needed regardless of which level between 2 and 5 the office visit is, a move that is expected to save some time each day.

The CMS outlined its vision for changes to the E/M payment in the proposed update to the 2019 Medicare physician fee schedule. Comments on the proposal are due Sept. 10, 2018.

The agency estimated that for most specialties, there would be minimal effect on this proposed change. However, for 10 specialties, payment reductions could result from this change.

Specialties identified as potentially losing less than 3% of their overall payment include allergy/immunology, audiologists, hematology/oncology, neurology, otolaryngology, pulmonary disease, and radiation oncology and radiation therapy centers.

Rheumatologists are expected to lose 3% of their pay from the proposal, while dermatologists and podiatrists are expected to lose 4%.

On the flip side, obstetricians/gynecologists are expected to see a 4% bump because of this proposal, while nurse practitioners could see a 3% increase. Specialties expected to see an increase of less than 3% include hand surgery, interventional pain management, optometry, physician assistants, psychiatry, and urology.

The proposal is raising concerns, particularly from those who stand to see their pay reduced by the proposal.

CMS "has proposed a disastrous plan that would force most neurologists not just to abandon Medicare participation, but also to refuse treatment to Medicare patients," Marc Raphaelson, MD, chair of the American Academy of Neurology's Coding Subcommittee and the Academy's representative to the Relative Value Scale Update Committee, wrote in a report. "The AAN is responding vigorously that one size does not fit all. One visit type does not fit our patients or our practices. Neurologists could not sustain our practices at the proposed payment rates."

Dr. Raphaelson noted that the AAN applauds the agency's "willingness to abandon medically irrelevant charting that contributes to our frustration and burnout. CMS has brought payment and documentation reform into a bright light. In return, it is up to the AAN, and our collegial medical societies, to propose a fair and transparent way to pay doctors for the work we really do."

The AAN recently joined the Americal College of Rheumatology (ACR) on Capitol Hill to raise awareness of the proposed cuts.

Dr. Angus B. Worthing is chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area

Dr. Angus B. Worthing

“Rheumatologists are pretty concerned about this,” Angus B. Worthing, MD, chair of the ACR’s Committee on Government Affairs, said in an interview. “Being a cognitive specialty ... we see patients who have complex or multiple issues and we focus more in the clinic on cognitive services, instead of procedural services.” He noted that rheumatologists bill across the E/M levels so it would be difficult to suggest a flat fee that would keep them from losing money.

Dr. Worthing, whose practice is in the Washington, D.C., metro area, said that about 70% of the Medicare payment covers overhead for the practice, leaving 30% to go toward the rheumatologist’s salary. To illustrate the impact of the proposed 3% cut, Dr. Worthing used the hypothetical of a current $100 payment turning into a $97 payment under the proposal. The overhead doesn’t change, so the physician’s portion that goes toward his salary drops 10% when it decreases from $30 to $27.

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