Most healthcare players agree the evaluation and management billing codes used by CMS need an overhaul, but few like the manner to do so proposed by the agency.
Some specialists are calling for the proposed rule to be put on hold (a final rule drop is expected next month). Oncologists in particular are voicing their frustration, and would be among those hardest hit financially, with office visit payments likely to drop about 15% under the proposal.
While clinicians and hospital groups have pushed for an easing of paperwork requirements for years, what they weren't expecting, and what many say they never asked for, was a change to E/M billing codes proposed in 2019 Physician Fee Schedule. The change would consolidate billing codes for office visits, an effort to reduce documentation and reporting requirements.
The overwhelming majority oppose the proposal, which would whittle payment rates for eight existing office visit services for new and established patients down to two. Specialists say flat payment rates aren't adequate for physicians who spend more time with patients with complex conditions and would incentivize quicker, more frequent visits.
And not just doctors oppose the changes. Some advocating for patients say it's too radical a change and echo the worries about specialties such as palliative care and oncology.
Finalizing the rule as is would have "significant perverse effects" on patient care, Robert Berenson, a visiting scholar at Families USA and a former CMS official during the Clinton administration told Healthcare Dive.
He advocated for the inclusion of patient and consumer groups in what is expected to be a CMS-sanctioned working group composed largely of clinicians.
"It seems to me, although some specialties would have done pretty poorly under this [rule], the real stakeholder group that would have been harmed are patients," Berenson said. Patients, he added, aren't complaining that physicians are seeing them for too long, and this rule would incentivize clinicians to spend less time with their patients.
Caitlin Donovan, director of public affairs at the National Patient Advocate Foundation, which advocates for low-income patients, told Healthcare Dive that the E/M proposal could allow doctors to start "cherry-picking healthier patients" by collapsing payment rates and compensating the same amount for all patients.
While NPAF is generally supportive of changes that lessen the amount of paperwork for clinicians, Donovan said, the rate collapse will mean multiple appointments for patients with complex conditions — a change she says will negatively impact lower-income patients, who are often sicker and face transportation barriers.
In a video about the proposed changes published in July, CMS Administrator Seema Verma said the move to revise E/M rules was fueled by the Trump administration's executive order requiring agencies to review and modify regulations and informed by conversations with providers.
"One thing we heard consistently from clinicians is that the documentation requirements imposed by CMS are so unnecessarily burdensome, redundant and time-consuming, that they are impacting the doctor-patient relationship, so critical to quality care," Verma said. "This administration has listened, and we are responding."
Public comment on the rule closed Sept. 10, but the agency has yet to respond to industrywide criticism of its E/M proposal, and did not respond to Healthcare Dive's requests for comment before publishing time.
While most providers are hoping to will a CMS-sanctioned stakeholder group into existence and push a rule on E/M back at least a year, CMS' next step is uncertain.
E/M policy due for an update
CMS implemented its original E/M documentation guidelines in 1995, with an update in 1997 in an attempt to prevent physicians from up-coding, or inflating billing codes to receive a higher payout. The update gave instructions on ways to document how much work was done during an office visit.
Berenson said the guidelines had "perverse effects" on patients and their medical records.
"The guidelines are abominable," Berenson said. "They didn't actually prevent up-coding. In addition to that, it cluttered the medical record with extraneous, often inaccurate information."
Those problems were amplified by the widespread implementation of EHRs. Faced with hours of tedious note-taking, physicians have found ways to game the system by essentially using up-coded billing templates to treat beneficiaries of similar ages, according to a 2012 OIG report.
EHR vendors are also not on board.
In a statement to Healthcare Dive, Sasha TerMaat, vice chair of the EHR Association's executive committee and director at Epic, focused on the lack of nuance in the proposal.
"That's why it's hard to assess important questions regarding the impact of proposed changes," TerMaat said. "How much time will clinicians save based on reduced Medicare documentation requirements? Will other payers follow? If other payers don't follow, what's the complexity of meeting one set of Medicare requirements and a second set of requirements from other payers? Will I as an individual clinician see an increase or decrease to my payments based on this proposal? How much?"
Berenson said industry professionals have been clamoring to change the guidelines "for years," but many physicians have an interest in "keeping the status quo" and protecting a system that he believes ultimately benefits clinicians at the expense of patients.
"We have a serious problem," Berenson said. "But we don't know what the solution is."
Industry suggests time out
The resounding response to CMS from industry has been to propose holding off on adopting the E/M proposal for at least a year while the medical community comes up with an alternative.
Led by the American Medical Association, 170 industry groups sent a letter to CMS Administrator Seema Verma asking her to support the creation of a "workgroup of physicians and other health professionals with deep expertise in defining and valuing codes" that would "arrive at concrete solutions" that would be implemented in 2020.
That suggestion was echoed by an additional 126 specialty groups that signed a letter to CMS urging the agency to "not to move forward with the proposal as it currently stands, and instead convene stakeholders to identify other strategies to reduce paperwork and administrative burden that do not threaten patient access to care."
Berenson expressed concern with healthcare consumer and patient advocacy groups delegating leadership on an E/M alternative to a stakeholder group under the auspices of AMA. Patient advocates argue that if a stakeholder group is sanctioned by CMS, patients deserve a place at the table — a notion Donovan said comes with its own set of snags.
Lower-income patients, for example, would be most dramatically affected by the rule, but they're also the most socioeconomically disadvantaged patient population and face factors that could easily prevent the ability to attend regular meetings.
"It will be a majority physician group," Donovan said. "That's OK. This is really more of a provider issue. It's great if you're considering patients, but this is something providers need to figure out."
The letter issued to CMS by the AMA-led group did voice some concern with the proposed rule's potential impact on quality of care and patient costs. The groups argued that the rule would result in "significant payment cuts for specialty care involving face-to-face visits with patients who have complex care needs" and penalize doctors who treat patients with complex conditions.
While CMS attempted to mitigate the risk to specialties by creating add-on codes to pay clinicians who treat sicker, more complex patients, specialists have said the effort falls short of solving the problems the larger proposal would create.
Both the American Society of Clinical Oncology and the Oncology Nursing Society opposed the complete E/M package and asked CMS to withdraw it.
"Although we appreciate the agency's efforts to partially offset these cuts with add-on code payments, the proposal does not appear to fully offset the direct and indirect cuts to oncology reimbursement, is ambiguous and lacks assurances of long-term durability," ASCO's comment reads.
Dede Sweeney, director of government affairs at the nursing group, told Healthcare Dive the organization is not looking to elaborate on its comments at this time.
Oncologists are possibly chief among those concerned with the rule's potential impact on payments for specialists. AMA estimates payment for office visits would decrease by 16% for hematologists, 16% for gynecology/oncology and 14% for medical oncology, the second, third and fourth hardest-hit specialties, respectively.
Donovan said NPAF is concerned with payments for hospice and palliative care, a specialty that treats an oft-neglected group. That fear is affirmed by AMA's estimates: Payments for hospice and palliative care visits would be hit the hardest of all specialties, dropping an estimated 20%.
Despite the controversies over the proposal, it has forced a factional industry to reconcile with a common, longstanding problem.
"Everyone knows the current system doesn't work very well," Berenson said. However, nobody has wanted to concede in order to create consensus. "Everyone's second choice has been to do nothing, and that has been the problem."