Physician Practice

Focus on medical-decision making, time may newly define E/M services

Physician Practice Insider, August 7, 2017

You may find significant changes to E/M reporting in the near future, including a pivot away from two key elements — history and physical exam — that largely determine a given level of service for your most common patient encounters.

In a request for comments about the suite of E/M codes that practices bill hundreds of millions of times per year, CMS is paving the way for a “multiyear, collaborative effort” that would achieve “comprehensive reform of E/M documentation guidelines,” according to the proposed 2018 Medicare physician fee schedule released July 13.

Don’t expect the changes to roll out by 2018. The long-term language that CMS uses in the proposed rule suggests the reform may be several years away. “Maybe something for 2019, but I would be surprised,” predicts Betsy Nicoletti, president of Medical Practice Consulting in Northampton, Mass.

However, the intent to overhaul the way that providers report — and the criteria for which payers reimburse — is not without merit, posits Nicoletti. Because the guidelines were put in place before the wide-scale adoption of electronic health records (EHRs), which can make it easier to bring in a patient’s health history, it’s “a very sensible thing to rethink how we value the intensity of E/M services,” says Nicoletti.

CMS points to new technology as a potential source of mistaken coding. “The guidelines have not been updated to account for significant changes in technology, especially [EHR] use, which presents challenges for data and program integrity and potential upcoding given the frequently automated selection of code level,” states the proposed rule.

“History and exam elements required in the 1995 and 1997 guidelines for higher-level services are no longer effective in an EHR environment because normal findings flood the pages of the medical record and the real concerns and decision-making [are] lost,” adds Valerie Rock, CHC, CPC, senior manager with consultancy PYA in Atlanta.

This article was originally published in Part B News. Subscribers can read the full article in the July 24, 2017, issue.


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