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How the Physician Fee Schedule Final Rule Will Change Health Care in 2019

Estimated read time: 6 minutes

For two decades, the health care industry has been concerned about the medical record documentation guidelines for evaluation and management services – a category of the Current Procedural Terminology code set used to bill outpatient and office procedures. The requirements, which were released by the Centers for Medicare and Medicaid Services in 1997, are considered by many to be burdensome and often result in incorrect, insufficient and unhelpful information. 

To fix these issues, the 2019 Physician Fee Schedule final rule makes significant revisions to the evaluation and management services documentation requirements and updates the payment policy.

Changes to evaluation and management documentation and payment

The following adjustments to the 2019 payment year documentation requirements will streamline workflows and empower providers to spend less time on paperwork and more time with their patients:

  • Documentation will focus on changes that happened since the last visit. 
  • Physicians do not have to re-document the chief complaint and history if the staff or patient has already provided it in the medical record.
  • Teaching physicians are not required to re-document what has already been recorded by residents or other members of the medical team.
  • There is no requirement for documentation of medical necessity for home visits. 

More simplification will come in the 2021 payment year, with providers getting the option to use either the duration of time spent completing all parts of a visit or medical-decision making to report office and outpatient evaluation and management visits.   
Despite the obvious benefits, there is good reason to proceed with caution when evaluating how practitioners can take advantage of these changes. First, these updated procedures only apply to professional services that are provided under Medicare Part B for office/outpatient visits and have not yet been adopted by other payers. This might cause confusion for providers as they deal with different health insurance plans and transition between private practice and hospital settings. It is important for affected providers to be diligent in aligning their documentation practices with the various patient and care setting needs. 

Further, the simplification in documentation requirements may have unintended impacts to the legal component of medical record documentation that may be needed to defend an audit or a medical malpractice suit. Providers and their governing bodies will need to carefully weigh these implications and develop standard practices.
The Centers for Medicare and Medicaid Services also introduced a simplified payment system which is slated to begin in the 2021 payment year. This includes a single payment rate for evaluation and management visits from levels 2 to 4 and individual rates for levels 1 and 5. The traditional set of Current Procedural Terminology billing codes, which distinguishes visits based on site and acuity of service for new or established patients, will continue to be used. New add-on codes will also be introduced to recognize resource costs for different types of evaluation and management visit complexities and extended visit times.
The Centers for Medicare and Medicaid Services has provided limited details about the implementation of the new documentation framework and payment system. Over the next two years, the federal agency plans to further refine this policy before the final implementation on January 1, 2021.

Telehealth expansions

The 21st Century Cures Act of 2016 provided a clear signal for the Centers for Medicare and Medicaid Services to advance telehealth in the Medicare payment system. The organization introduced two new telehealth "pre-visit consultation" services that will be used to evaluate whether a patient needs to be seen by a provider. These screening services allow established patients to have brief virtual check-ins and evaluation of pre-recorded store-and-forward patient information.  The Centers for Medicare and Medicaid Services believe these visits will be beneficial for treatment of opioid and other substance use disorders.  

Just before the final rule was published, President Donald Trump signed the SUPPORT Act for Patients and Communities into law. The Centers for Medicare and Medicaid Services included provisions from this law into the final rule, which added telehealth service eligibility for a substance use disorder diagnosis or co-occurring mental health disorder, regardless of geographic location.

We have also seen several rules this year which stretch the geographical reach of telehealth, bringing services to previously uncovered locations. As this technology continues to grow, organizations should examine how telehealth services can provide them with greater financial savings and improvements to patient and care team satisfaction. 

Integrating appropriate use criteria

In the 2018 Physician Fee Schedule rulemaking, the Centers for Medicare and Medicaid Services finalized the requirement to consult clinical guidelines, or appropriate use criteria, intended for use in decision support interactions. Starting January 1, 2020, providers who are ordering advanced diagnostic imaging services are required to consult a Qualified Clinical Decision Support Mechanism in the applicable appropriate use criteria during the patient workup. 

In the 2019 final rule, the Centers for Medicare and Medicaid provided instructions on the use of claim-based reporting of G-codes and modifiers for the appropriate use criteria. They also defined temporary hardship exceptions, including insufficient internet access, vendor issues or extreme and uncontrollable circumstances. These hardships do not align with other programs and must be self-attested by the practitioner at the time of placing the order. 

It is important to note the Centers for Medicare and Medicaid allow the first year of appropriate use criteria reporting in 2020 to be an "educational year" in which payment will not be withheld for failure to include the correct appropriate use criteria information on the claim. Although there has been speculation that this means the appropriate use criteria does not have to be provided during this testing period, the language in the final rule states: 
“Ordering professionals must consult specified applicable appropriate use criteria through qualified Clinical Decision Support Mechanisms for applicable imaging services furnished in an applicable setting, paid for under an applicable payment system and ordered on or after January 1, 2020; and furnishing professionals must report the AUC consultation information on the Medicare claim for these services ordered on or after January 1, 2020.”

Providers who do not meet the thresholds of appropriate use criteria consultation will be penalized with a prior authorization requirement for all advance diagnostic imaging orders. The Centers for Medicare and Medicaid Services will use data collected in 2021 to define the thresholds. It is imperative to have the appropriate use criteria consultation performing smoothly in 2020 to align with the 2021 data collection and avoid penalties in 2022.

While the complex regulatory changes from the 2019 Physician Fee Schedule final rule require health care organizations to do some thoughtful planning and preparation to stay compliant, the shift toward more modern and efficient care is a positive change for both consumers and providers. 

Cerner can help your organization stay ahead of the curve with new regulatory requirements. Learn more here.