2018 Physician Fee Schedule Recommendations
Medicare is accepting public comments on their proposed changes to the 2018 Physician Fee Schedule until September 11, 2017. I will be making comments on a few critical issues. The comment drafted below pertains to Medicare's proposal to eliminate the history and exam components of the documentation guidelines for evaluation and management services.
I. Evaluation & Management (E/M) Guidelines and Care Management Services
Thank you for the opportunity to comment on Medicare's proposal to eliminate the history and exam components of the E&M Documentation Guidelines. I have educated physicians to achieve compliance with the guidelines since they were in draft form, I have audited thousands of visit notes for compliance, and I have secured several clarifications from Medicare officials regarding how the guidelines should be applied.
Most of the confusion regarding the history and exam portions of the evaluation and management documentation guidelines was created, compounded, and perpetuated by Medicare and the Medicare Administrative Contractors (MACs). Rather than eliminating the requirements for physicians to document history and exam, Medicare should eliminate the ambiguities in the guidelines and require all MACs to apply the uniform standard.
Here are a few examples of how Medicare and MACs have created, compounded, and perpetuated confusion:
I recommend the following:
Addressing the challenge in this manner will eliminate most of the confusion acknowledged in the proposed rule and avoid the many burdens associated with creating and transitioning to a new documentation standard. Many physicians are already overwhelmed by administrative burden, fine-tuning the existing guidelines will achieve the goals of Medicare with minimal additional burden.
Physician Fee Schedule Excerpt - "We are also seeking comment on how such reforms may differentially affect physicians and practitioners"
Eliminating the history and exam portions of the guidelines would exacerbate and perpetuate the confusion that currently exists. The following excerpts from the proposed rule illustrate this:
The first excerpt proposes to eliminate the documentation requirements, the second proposes that the history and exam must still be "consistent with complexity of MDM." There has never been any correlation between the complexity of MDM and the levels of history or physical - they are three moving pieces that frequently don't align. A guideline to define what documentation is consistent with complexity of MDM would be more confusing than the existing history and exam requirements.
Physician Fee Schedule Excerpt - "We are additionally seeking comment on whether CMS should leave it largely to the discretion of individual practitioners to what degree they should perform and document the history and physical exam."
I don't support the idea of "leaving it to the discretion of the individual practitioners." This would reward those who are comfortable pushing their luck and penalize those who have been sufficiently intimidated by the regulatory focus on the documentation guidelines to date.
Physician Fee Schedule Excerpt - "The guidelines have not been updated to account for significant changes in technology, especially electronic health record (EHR) use... in addition, an increase in the utilization of EHRs, and to some extent, shared health information via EHRs, may have changed the character of extended patient histories since the guidelines were established."
Most EHRs were designed around the E&M Documentation Guidelines. Updating the documentation guidelines to adapt to EHR technology would create more confusion and cost a lot of money. Medicare has indicated that it is looking into inappropriate EHR use, cloned medical records, and copy/paste capabilities. However, no clear guidelines have been issued by Medicare about what is appropriate and inappropriate in regards to EMRs. There should be clear guidelines and Medicare might be able to incorporate appropriate checks and balances into future EHR accreditation standards.
Physician Fee Schedule Excerpt - "We also welcome comments on specific ideas that stakeholders may have on how to update MDM guidelines to foster appropriate documentation for patient care commensurate with the level of patient complexity, while avoiding burdensome documentation requirements and/or inappropriate upcoding. "
Similar to the history and exam components of documentation, Medicare allows MACs to interpret the MDM portion of the guidelines and to change their positions at will. The Marshfield Clinic Audit Tool establishes a framework that many utilize but MACs differ regarding multiple components of the audit tool:
Independent Visualization of ECGs
The data calculation of medical decision making awards 2 points for independent visualization of ECG tracings and 1 point for ordering an ECG. The four files presented below illustrate how Medicare and MACs created and compounded confusion regarding these rules. The first document presents Medicare's position in 2004, the second one shows how Novitas established a different standard in 2009, and the third shows how Novitas reversed their position in 2016.
No More Consultation Codes
CMS' proposal to eliminate the history and exam key components of documentation is akin to Medicare deciding to ignore all consultation codes (99241 – 99245 & 99251 – 99255) in 2010. Prior to that, physicians were badgered to learn and apply the “3 Rs” of consultations. When electronic medical records began to flourish, questions arose regarding how the 3 Rs could be met. Because Medicare received too many questions regarding this issue, it decided to stop recognizing the consultation codes. That change created, compounded, and perpetuated confusion. Because non-Medicare payers did not ignore the consultation codes, healthcare organizations now need to code and report services differently based on payer. See CMS announcement by clicking the button below...
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