Editors: Nutan De Joubner, M.D. | Erica Huffman, Executive Director
www.escambiacms.org
Bulletin JULY/AUGUST 2018 VOLUME 48, NO. 4
CONTENTS Have you read the recent letter to doctors by the CMS administrator, Seema Verma? More change is coming for physicians trying to practice under the convoluted rules and regulations of Medicare. Physicians who participate in Medicare just endured the implementation of MACRA and MIPS, a massive restructuring of the Medicare payment system but CMS has decided that more change is necessary. As always, the changes are being promoted as something from which physicians will benefit. These changes will be an effort to rein in the excessive administrative burden by the cumbersome documentation requirements, coding rules, and quality measures placed on doctors by Medicare. There may be validity to the fact that use of Evaluation and Management (E&M) codes has turned out to be a complicated mess which puts perverse incentives in place encouraging physicians to upcode every visit in order to maximize reimbursement. In fact, when the concept of the E&M codes was first introduced, we were all encouraged and given explicit instructions on how to upcode every visit by the army of coding specialists who are now so prevalent in medicine. This coding system was always rife for misuse. Our once succinct, relevant doctor’s notes are now padded with ‘documentation,’ mostly irrelevant to us as physicians, but mandatory to CMS in order to justify a higher E&M code.
increased complexity. The new CMS rules would change the structure of the E&M codes, going from 5 levels (99211-99215) to one. There would be one code and one reimbursement fee for all follow-ups, no matter the complexity, and one code and reimbursement for new patients, no matter the time spent seeing the patient. For example, the healthynew patient with a stress fracture of the foot will apparently have the same reimbursement as the critically ill new patient with Scleroderma, interstitial lung disease and digital ulcers. We have yet to learn what the actual reimbursement fee will be. I speculate that it will be somewhere between what is presently reimbursed for a 99213 and a 99214 visit. To quote the CMS administrator in her recent letter to doctors, “We’ve proposed to move from a system with separate documentation requirements for each of the 4 levels that physicians use to a system with just one set of requirements, and one payment level each for new and established patients. Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden.”
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Physicians feel compelled to list a multitude of diagnoses, which often make our patients appear sicker than they actually are, because managing the sicker patients allows for upcoding based on
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