Radical Changes on EM Payments and Documentation Requirements Proposed by CMS - CAH CFO-Administrator Forum

Radical Changes on EM Payments and Documentation Requirements Proposed by CMS

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Centers for Medicare & Medicaid Services (CMS) has proposed radical changes for the new and established outpatient visits (99201-99215) with regards to documentation and creating a uniform payment for evaluation and management (E/M) services, regardless of the level of service reported.

Highlights of the Proposed Changes    

PROPOSAL 1: Documentation Requirements Gets Flexible

Simplify the documentation of history and exam for established patients such that, for both of these key components, practitioners would only be required to focus their documentation on what has changed since the last 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.

CMS also proposed, for both new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the chief complaint and history that are already entered by ancillary staff or the beneficiary. The practitioner could simply indicate in the medical record that they reviewed and verified this information.

In every case, CMS would expect the provider to continue to document history and exam to the extent required to provide quality care. The goal is to allow practitioners more flexibility to exercise greater clinical judgment and discretion in what they document, focusing on what is clinically relevant and medically necessary for the patient. CMS expectation is that practitioners would continue to periodically review and assess static or baseline historical information at clinically appropriate intervals.

PROPOSAL 2: Report EM Level based on MDM or Time

Under current E/M documentation guidelines, the history and exam are two of the three required elements, along with medical decision-making (MDM), to be considered when selecting the overall level of E/M service for reporting. CMS proposes to eliminate the history and exam from consideration. As a result, MDM would stand as the sole determinant of E/M service level.

Providers could continue to use time as the determining factor in selecting an E/M service level. CMS states in the proposed rule, “For practitioners choosing to support their coding and payment for an E/M visit by documenting the amount of time spent with the patient, we propose to require the practitioner to document the medical necessity of the visit and show the total amount of time spent by the billing practitioner face-to-face with the patient.”

PROPOSAL 3: Pay Single Rate for Level 2-5 E/M Visits

In return for simplified documentation requirements and coding guidelines, CMS proposes streamlined E/M payments. Essentially, there would be two reimbursement levels for new patient visits (99201 and 99202-99205), as shown in Table A, and two reimbursement levels for established patient visits (99211 and 99212-99215), as shown in Table B.

HCPCS Code CY 2018 Non-facility Payment Rate CY 2018 Non-facility Payment Rate under the Proposed Methodology
99201 $45 $44
99202 $76 $135
99203 $110
99204 $167
99205 $211
Table A: Proposed Reimbursement Levels for New Patient E/M Visits

HCPCS Code CY 2018 Non-facility Payment Rate CY 2018 Non-facility Payment Rate under the Proposed Methodology
99211 $22 $24
99212 $45 $93
99213 $74
99214 $109
99215 $148
Table B: Proposed Reimbursement Levels for Established Patient E/M Visits

CMS’s proposals to simplify the documentation requirements and to pay a single PFS rate for new patient E/M vis it levels 2 through 5 and a single rate for established patient E/M visit levels 2 through 5 are finalized, practitioners would still bill the CPT code for whichever level of E/M service they furnished and they would be paid at the single PFS rate. However, CMS believes that eliminating the distinction in payment between visit levels 2 through 5 will eliminate the need to audit against the visit levels, and therefore, will provide immediate relief from the burden of documentation.


Home Visits

CMS is proposing to remove the requirement that the medical record must document the medical necessity of furnishing the visit in the home rather than in the office” since CMS agrees with stakeholders suggestion that whether a visit occurs in the home or the office is best determined by the practitioner and the patient without applying additional rules.

Add-on EM Codes

An add-on G code for primary care will cover resource costs associated with primary care E/M services. A second G code would apply for specialties in which E/M services make up a large percentage of overall charges, including:
  • Endocrinology
  • Rheumatology
  • Hematology/Oncology
  • Urology
  • Neurology
  • Obstetrics/Gynecology
  • Allergy/Immunology
  • Otolaryngology
  • Cardiology
  • Interventional Pain Management

The add-on G code would represent the complexity inherent to E/M services in these specialties.

Multiple-service Payment Adjustment

An E/M multiple procedure payment adjustment to account for duplicative resource costs when E/M visits and procedures with global periods are furnished together. Essentially, this means CMS would reduce payment by 50 percent for E/M services that are submitted with modifier 25 Significant, separately identifiable Evaluation and Management (E/M) by the same physician or other qualified health care professional on the same day of the procedure or other service on the same day as a zero global day procedure.



Whether CMS follows through with all (or any) of its proposals depends, in part, on stakeholder comments. Whatever the outcome, the decision will be detailed in a final rule. Stay tuned with our newsletters for update on the final rule.

The CMS proposal doesn’t alter the actual CPT® codes (owned and copyrighted by AMA) or descriptors for E/M services, only the federal government documentation requirements and assigned payments for these services.

The AMA explained it is evaluating how this proposal will affect patients, especially those with complex conditions, and will also evaluate the impact across various types of patients and specialty practices before altering the CPT® E/M codes.


  • Centers for Medicare & Medicaid Services (CMS). (2018). Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS) Proposed Rule. Retrieved from Centers for Medicare & Medicaid Services (CMS): https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2019-PFS-NPRM-Doc-Requirements-and-Payment-E-M-Visits-and-Advancing-Virtual-Care.pdf
  • Centers for Medicare & Medicaid Services (CMS). (2018, July 12). Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019. Retrieved from Centers for Medicare & Medicaid Services, CMS: https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-3
  • Ericson, B. (2018, September 4). Are CPT® E/M Codes Changing? Retrieved from AAPC : https://www.aapc.com/blog/43691-are-cpt-em-codes-changing/

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