August 09, 2018

CMS Proposes Changes to E/M Rules and Payments

The 2019 Medicare Physician Fee Schedule proposed rule features proposed changes to the structure and payment of evaluation and management (E/M) services.

Physician stakeholders have long maintained that all E/M documentation guidelines are administratively burdensome and outdated with respect to the practice of medicine. In response to these concerns, the Centers for Medicare and Medicaid Services (CMS) proposed to reduce the documentation requirements for most E/M services. In conjunction with the reduced documentation requirements, CMS also proposed reduced reimbursement rates for higher-level E/M visits.

Specifically, CMS proposed that practitioners only be required to focus documentation on what has changed since the last patient visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history. Additionally, the agency proposed that for both new and established patients, practitioners would no longer be required to re-enter information in the medical record that is already entered by ancillary staff or the beneficiary. Rather, the practitioner could indicate that they reviewed and verified the information.

CMS believes a payment reduction was warranted with the proposal to reduce the documentation requirements for E/M visit levels 2 through 5. Therefore, CMS proposed to simplify the payment for those services by paying a single rate for the level 2 through 5 E/M visits. As a result, level 4 and 5 consultations would see significant payment reductions. Many specialty societies have expressed concern that this proposal unfairly targets those physicians (including radiation oncologists) who see patients with complex disorders, which typically would be billed at a higher level. On the other hand, those physicians who primarily bill lower level E/M visits (including diagnostic and interventional radiologists) may see a payment increase as a result of the proposals.

CMS also proposed the development of new G-codes to account for inherently complex visits, though the reporting of these new codes is limited to certainly specialties.

Finally, CMS proposed a multiple procedure payment reduction when a procedure is performed on the same day as an E/M visit. In these cases, a 50 percent payment reduction would apply to the code with the lesser value.

ACR staff is continuing to evaluate the impact of these proposals on radiology, interventional radiology, nuclear medicine and radiation oncology practices and will provide comments on the proposals to CMS.

For questions, please contact Katie Keysor at