How E/M Documentation Will Change In The New Year

The Centers for Medicare and Medicaid Services (CMS) released the 2019 Physician Fee Schedule Final Rule in November, and it goes into effect Jan. 1. The proposal to create separate codes for podiatric evaluation and management (E/M) services was eliminated, and there will not be separate E/M codes for podiatrists. This was not a temporary ruling, but rather a final decision. However, the Final Rule does contain several changes pertinent to E/M services, some of which go into effect Jan. 1, 2019, and others that go into effect Jan. 1, 2021. These are listed below:

Effective January 1, 2019:

• Continue to use the CMS 1995 and 1997 Documentation Guidelines for Evaluation and Management Services.
• For established patients, focus documentation on what has changed since the last visit. Physicians do not need to rerecord the unchanged E/M elements if there is evidence that you reviewed the previous information and updated it as needed.
• For both new and established patients, providers do not need to reenter in the medical record information regarding the patient’s chief complaint and history that has already been entered by staff or the patient if the provider indicates in the medical record that he or she reviewed and verified this information.
• Teaching physicians no longer need to make notations in medical records that have previously been included by residents or other members of the medical team.
• It is no longer required to document the medical necessity of a home visit in lieu of an office visit.

Effective January 1, 2021:

• New office/outpatient E/M services CPT 99202–99204 will all reimburse at a single payment rate. This rate will fall between what the 2021 payments for CPT 99203 and 99204 would have been.
• Established office/outpatient E/M services CPT 99212–99214 will all reimburse at a single payment rate. This rate will fall between what the 2021 payments for CPT 99213 and 99214 would have been.
• The selection of level for both new and established office/outpatient E/M services levels 2–5 may be based on medical decision making or time or the 1995/1997 Documentation Guidelines for Evaluation and Management Services.
• When using medical decision making or the ‘95/’97 guidelines to determine the level of an office/outpatient evaluation and management service, if the level is between 2 and 4, you only need to reach the current level 2 thresholds for medical decision making or time.

Dr. Lehrman operates Lehrman Consulting, LLC, is a consultant to the APMA Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Certified Professional Coder. Follow him on Twitter @DrLehrman

References

1. Federal Register. Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; etc. Available at https://www.federalregister.gov/public-inspection/current .

2. Centers for Medicare and Medicaid Services. Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019. Available at https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year . Published Nov. 1, 2018.