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AMA, AAFP, ACP: CMS should reconsider proposed physician payment policies
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CMS is currently reviewing more than 15,000 comments it received regarding its proposals that would overhaul physician payment policies and reduce clinician burden in 2019, an agency spokesperson told Healio Family Medicine.
The agency’s major proposals include: Simplifying, streamlining and offering flexibility in documentation requirements for Evaluation and Management (E/M) office visits; and removing burdensome and overly complex functional status reporting requirements for outpatient therapy.
“[These] reforms proposed by CMS bring us one step closer to a modern health care system that delivers better care for Americans at a lower cost,” HHS Secretary Alex Azar said in a press release at the time the proposals were announced in July.
He also called the proposals “historic,” and claimed they would help clinicians put patients over paperwork. CMS’ also said the ideas are based on input from clinicians and stakeholders.
However, many medical societies think the proposed changes only address some of the problems the clinicians face.
AMA and the American Academy of Family Physicians had questions regarding how CMS developed its coding guidelines for E/M services.
“Regarding the proposal to collapse payment rates for eight office visit services for new and established patients down to a total of two, that is where the unanswered questions linger,” AMA said in a statement. “As written, they would hurt physicians who treat the sickest patients as well as those who provide comprehensive primary care, ultimately jeopardizing patients’ access to care. The AMA does not think that the authors of this rule intended to limit coverage for patients who require complex services, but that would be the result. The AMA’s response letter urges CMS to set aside this part of the proposal.”
“We are unclear how CMS arrived at its proposed [relative value units] for the add-on code," AAFP said in a letter to CMS. "We are unclear how less than two minutes of physician time and $5.40 ... 'accounts for the additional resource costs associated with furnishing primary care that distinguishes E/M primary care visits from other types of E/M visits.’”
AAFP claimed, “CMS further complicated the issue by proposing higher values for add-on codes for complex visits provided by subspecialists,” many of which are handled by primary care physicians.
The AAFP asked CMS to remove the primary care add-on code suggested and instead initiate a 15% increase in payment for E/M services provided by family physicians, internists, pediatricians and geriatricians.
In addition, AAFP asked CMS to eliminate the proposed 50% Multiple Procedure Payment Reduction for physicians who list their primary practice designation as family medicine, internal medicine, pediatrics, or geriatrics. As proposed, CMS would apply a 50% reduction in payment “for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit.”
ACP also had concerns about E/M related payments under CMS’ proposal.
“ACP is open to developing and pilot-testing blended payment alternatives, if they allow for differentiation in payment rates so that more complex E/M services are paid more than less complex ones, and simplify documentation requirements while addressing CMS’s program integrity concerns,” ACP president Ana María López, MD, MPH, FACP, said in statement.
“We [also] believe that the proposal to pay the same for complex cognitive care as more basic care will undermine patients who need our help the most. As proposed, a considerable number of physicians would be disadvantaged if they treat patients who are frail, sick, or more complex, and would be discouraged from spending time with them.”
Other statements released by AMA, AAFP and ACP since CMS unveiled its proposal suggest support for trying to alleviate physician burdens related to E/M.
AAFP agreed with CMS’ idea to mandate documentation at only the 99202 and 99212 coding levels and “was pleased” that CMS saw the importance of reviewing and revising documentation guidelines for E/M services that are “decades old.”
In addition, the AAFP, AMA, ACP and 167 other groups representing many other medical specialties and clinicians sent CMS a letter encouraging quick action be taken on the following proposals:
- Changing the required documentation of the patient’s history to focus only on the interval history since the previous visit;
- Eliminating the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or by the patient; and
- Removing the need to justify providing a home visit instead of an office visit.
These changes, if adopted, “would go a long way toward alleviating” the problem of having many pages of excessive information that makes it problematic in quickly locating important information about a patient’s current illness or test results, a problem the 170 medical societies dubbed “note bloat” in their letter.
A final rule on the E/M proposals is expected in November, the CMS spokesperson told Healio Family Medicine. – by Janel Miller