The AAMC Sept. 10 submitted comments to the Centers for Medicare and Medicaid Services (CMS), responding to the agency’s proposed rule changes in the Medicare Physician Fee Schedule and Quality Payment Program to take effect in calendar year (CY) 2019. CMS proposed major changes to payment and documentation for outpatient evaluation and management (E/M) services. It also proposed that Medicare cover newly-established interprofessional internet consultation codes and recommended changes and updates to the quality payment program (QPP).
CMS proposes to pay a single payment rate ($135) for E/M levels two through five visits for new patients (99201-99205) and a separate single payment rate ($93) for levels two through five visits for established patients (99212-99215). CMS also has proposed three add-on codes to recognize additional relative resources for certain kinds of visits. To fund the add-on payments, CMS proposes a multiple procedure payment reduction (MPPR) that would reduce payment by 50% for the least expensive procedure or visit when a procedure is performed on the same day as an office visit.
The AAMC opposes the proposal to establish single payment rates for outpatient/office visits (99202-99205 and 99212-99215), the proposed MPPR, and the proposed add-on codes for primary care, inherent complexity, and prolonged services, because the changes would hurt physicians who treat more complex patients and result in numerous unintended consequences. The letter recommends that CMS work with stakeholders on implementation of a new approach.
To reduce the administrative burden physicians experience in billing for treatment of Medicare patients, CMS proposed substantial changes to E/M documentation by allowing physicians to choose one of the following documentation methods: 1) current framework of evaluation guidelines from 1995 or 1997, 2) medical decision making, or 3) time. In addition, CMS proposes to reduce redundancy of documentation by eliminating the requirement that physicians re-document information already in the patient’s record, as well as by requiring documentation of only the interval history since a patient’s last visit. The AAMC supports these documentation proposals and recommends that CMS finalize them.
Additional comments include:
- The AAMC supports the CMS proposal that would allow medical records to show that a teaching physician was present at the time of service, with documentation made by the physician, resident, or a nurse.
- The AAMC supports CMS’ efforts to modernize Medicare physician payment by recognizing communication technology-based services and is particularly supportive of CMS’ development of new internet interprofessional consultation codes (994X0 and 994X6). The AAMC requests that CMS use the RVS Update Committee-recommended values of these codes (0.50 and 0.70) instead of valuing them both at 0.50.
- The AAMC supports CMS exploring options for a subgroup to report separately on QPP measures and activities that are more applicable to the subgroup and be assessed based on performance of that subgroup. This would be of interest to many teaching hospitals that participate in large, multispecialty group practices.
- The AAMC disagrees with CMS’ proposal to weight the cost performance category at 15% instead of the current use of 10% and recommends continued use of the 10% weight.
- The AAMC requests that cost measures be adjusted appropriately to account for sociodemographic status risk factors.
- The AAMC is concerned with the most recent cost category feedback reports, noting that missing from the reports is detailed information that helps providers determine how they are performing or how their performance compares to other providers. The absence of such data inhibits providers’ ability to make improvements.
- The AAMC suggests aligning interoperability programs as much as possible.
- The AAMC supports CMS’ decision that the generally applicable revenue-based nominal amount standard should remain at 8%.
- The AAMC notes that eligible clinicians are taking on additional risk in advanced alternative payment models (APMs) as the thresholds to be a qualified participant will increase to 75% of Medicare payments and 50% of Medicare patients over the next several years. The AAMC recommends that CMS review information about physician participation in advanced APMs before deciding whether to change the amount of required financial risk, since a downside risk that is set too high will create a barrier to physician participation.
In response to these concerns, which the AAMC and numerous provider groups representing diverse specialties raised, Reps. Brad Wenstrup (R-Ohio), Earl Blumenauer (D-Ore.), Marsha Blackburn (R-Tenn.), and Doris Matsui (D-Calf.), along with 86 House colleagues, sent a letter to CMS Administrator Seema Verma, urging the agency “to take additional time to work closely with physicians and other stakeholders to identify alternative approaches that would accomplish CMS’ goals while ensuring that physicians are reimbursed appropriately according to the level of care required by each individual patient’s condition.”
Sens. Bill Cassidy (R-La.) and Sherrod Brown (D-Ohio) are circulating a Senate version of the House letter, which they expect to send to CMS soon.