2018 Physician Fee Schedule Recommendations
In their 2018 Proposed Physician Fee Schedule, Medicare solicited comments regarding their idea of replacing 2/3 of the Evaluation and Management Documentation Guidelines with a standard that would be completely open to interpretation by Medicare auditors.
I took them up on the opportunity and submit the following comment. You can also view the proposed fee schedule by clicking the link below.
I. Evaluation & Management (E/M) Guidelines and Care Management Services
I have helped physicians achieve compliance with the E&M Documentation Guidelines since they were in draft form, I have illustrated how the documentation guidelines apply to thousands of visit notes, I have guided physicians through several Medicare audits, and I secured several clarifications regarding how the guidelines should be applied from Medicare and its administrative contractors.
Medicare published a set of guidelines and told all physicians that they must follow them. Failing to follow the guidelines could result in financial penalties in excess of $10,000 per claim, sanction from all government funded programs, and prison time. In response, physicians attend training programs, organizations voluntarily audit millions of visit notes each year, organizations implement expensive electronic medical record programs, and physicians change the way they practice to achieve compliance with these documentation guidelines. Medicare is now seeking public comment regarding the idea of eliminating two thirds of the guidelines.
Eliminating the history and exam components of the guidelines would necessitate considerable additional training for physicians, require electronic medical record programs to be overhauled, and it would create more variations between Medicare rules, instructions in the CPT book, Medicare contractors, and the rules enforced by non-Medicare payers. Clarification of the existing guidelines would be more efficient, effective, successful, and affordable than eliminating the history and exam components.
Most of the confusion regarding the history and exam portions of the guidelines was created, compounded, and perpetuated by Medicare and the Medicare Administrative Contractors (MACs). I recommend that Medicare eliminate the ambiguities in the guidelines, provide clear answers to provider questions, and require all MACs to apply a uniform standard.
Here are a few examples to consider:
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 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."
The proposed rule suggests that the history and exam elements might be removed in the first excerpt below. The second excerpt indicates that there would still be a documentation requirement:
There has never been a correlation between the complexity of Medical Decision Making (MDM) and the levels of History or Physical - they are three independently moving variables that frequently don't align. A guideline to define which History and Exam documentation is consistent with each level of Medical Decision Making would be more voluminous and confusing than the existing documentation guidelines.
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 to efficiently facilitate compliance with the E&M Documentation Guidelines. The documentation guidelines should be enhanced with clear rules regarding what is appropriate and inappropriate use of EHRs.
Over the last several years, Medicare has indicated that it is looking into inappropriate EHR use like cloned medical records and copy/paste capabilities. However, no clear guidelines have been issued by Medicare. The absence of a rash of prosecutions seems to support the practice of clicking a few buttons to have your EHR generate an audit-proof level five visit note.
There should be clear guidelines.
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. "
Like 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:
Regarding Chronic Care Management, I recommend that Medicare eliminate all out of pocket expenses for these services. Effective management of chronic conditions will substantially reduce the overall cost of care. Most of the most expensive hospital admissions could be avoided if chronic conditions were effectively managed. Providing coverage for chronic care management was a great idea. Unfortunately, the monthly co-insurance patients must pay is price prohibitive for many. Because of this, healthcare organizations are not comfortable dedicating the time and financing needed to initiate and maintain effective chronic care management programs.
Eliminating the out of pocket expenses for chronic care management and the cardiac rhythm management devices mentioned above would save a massive amount of money and prevent a massive amount of patient suffering.
Patient visits, coronary, peripheral vascular, pacemaker/defibrillator, electrophysiology, & device clinic
Turnkey billing solutions for private practices, effective outsourcing for cardiology service lines of hospitals.
Jim Collins, CPC, CCC