CMS Proposes to Revise Evaluation & Management Guidelines
October 10, 2017
According to the recently released 2018 Physician Fee Schedule Proposed Rule, published in the Federal Register, dated July 21, 2017, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current Evaluation and Management (E/M) documentation guidelines create an administrative burden and increased audit risk for providers. In response, CMS announced its intention to undertake a multi-year effort with the input of providers and other stakeholders to revise the current E/M documentation guidelines. This revision will likely include removal of the history and exam documentation requirements.
CMS states in the provision: "Stakeholders have long maintained that both the 1995 and 1997 guidelines are administratively burdensome and outdated with respect to the practice of medicine, stating that they are too complex, ambiguous, and that they fail to distinguish meaningful differences among code levels. In general, we agree that there may be unnecessary burdens with these guidelines and that they are potentially outdated, and we believe this is especially true for the requirements for the history and the physical exam. The guidelines have not been updated to account for significant changes in technology, especially electronic health record (EHR) use, which presents challenges for data and program integrity and potential upcoding given the frequently automated selection of code level."
While CMS conducts few audits on E/M visits relative to the volume of Medicare Physician Fee Schedule (PFS) services they comprise, they have repeatedly heard from practitioners about the administrative burden. CMS states in the proposed rule that their prior attempts to revise the guidelines met with a lack of stakeholder consensus and support, which contributed to the current policy that allows practitioners to use either the 1995 guidelines or 1997 guidelines, resulting in further complexity in determining or selecting the applicable requirements.
As a result, CMS is seeking input from a broad group of stakeholders, including patient advocates, on the specific changes they should undertake to reform the guidelines, reduce the associated burden, and better align E/M coding and documentation with the current practice of medicine.
CMS stated in the proposed rule that they are specifically seeking comment on how they might focus on initial changes to the guidelines for the history and physical exam as they believe documentation for these elements may be more significantly outdated, and that differences in Medical Decision Making (MDM) are likely the most important factors in distinctions between visits of different levels. Public comment on possibly eliminating the current focus on details of history and physical exam, and allow MDM and/or time to serve as the key determinant of E/M visit level is part of the proposed rule.