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Neurologists to lose money under CMS E/M proposal



Neurologists can expect decreased reimbursement under a proposal by the Centers for Medicare & Medicaid Services that would change how the agency pays for evaluation and management services (E/M), according to an analysis published in JAMA Neurology.

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The CMS recommendation, issued as part of the agency’s 2019 proposed Physician Fee Schedule, would collapse payments for new and established patients for office/outpatient E/M levels 2-5 (currently between $45 and $211) into single payments. The proposed single payments (return visits $93; new patients $135) are between current rates for levels 3-4. In its proposal, CMS officials said the change would improve payment accuracy and simplify documentation.

If approved, neurologists stand to lose the most money under the payment scheme since the majority of their Medicare payments stem from these services, while specialists who use the services less often would benefit from the modification. Specifically, neurologists would lose a median of $3,226 annually under the CMS proposal and cardiologists would lose a median of $3,203 per year, while dermatologists would gain an annual median of $16,655 and orthopedists would gain a median of $6,239, according to the study.

Lead author Brian C. Callaghan, MD, of the University of Michigan, Ann Arbor, and colleagues evaluated the 2013 Medicare Physician and Other Supplier File to determine the distribution of outpatient E/M codes for levels 2-5 used by different specialists and the proportion of total payments for all physician services attributable to these outpatient codes. Investigators estimated the financial impact of collapsed payments by calculating the difference of actual annual payments for outpatient E/M work and the projected annual payments with the proposed policy change.

Results showed that in 2013 the proportion of outpatient E/M codes billed at levels 4-5 varied widely by specialty. Neurologists for example, billed 70% of their outpatient physician E/M codes under levels 4-5, the highest of any specialty. Cardiologists were also high utilizers of the codes with 65% of their outpatient E/M codes falling between levels 4 and 5. The lowest users for levels 4-5 were dermatologists (11%), orthopedists (22%), and otolaryngologists (25%). Taking into account the distribution and volumes of E/M services, the investigators concluded that CMS’ proposed payment change would be most favorable for surgical specialists, neutral for generalists, and most unfavorable for neurologists.

Dr. Callaghan and colleagues wrote that collapsing E/M payments would likely incentivize all physicians to shorten visit times, which could negatively impact doctor-patient relationships and patient care.

“Given that longer visit times are associated with higher patient satisfaction and important elements of care, the CMS proposal would likely have negative consequence,” Dr. Callaghan and his coauthors wrote. “Current E/M payments strongly undervalue the cognitive work of physicians, compared with procedural-based payments. Based on our data, the recent proposal to collapse E/M payment levels would further undervalue these important services, particularly for neurologists.”

The authors reported receiving grants and fees from organizations, companies, and government agencies outside the published study.

SOURCE: Callaghan B et al. JAMA Neurol. 2018 Oct 31. doi: 10.1001/jamaneurol.2018.3794.

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