• Window of Opportunity Opening to Revalue E/M Codes

    "Look, if you had one shot or one opportunity to seize everything you ever wanted in one moment, would you capture it or just let it slip?"
    -- Eminem

    Back view of young businessman looking out of window in abstract jigsaw interior. Opportunity and solution concept. 3D Rendering

    The history of the U.S. health care system is full of inflection points where a critical decision was made and the trajectory of our health care system was changed in a substantive way. Although history hasn't always judged these changes favorably, they nonetheless altered our health care system in meaningful ways.

    We are approaching one of those moments, an inflection point that will have a consequential impact on patient care, your practice and our health care system. The magnitude of this inflection point will be determined largely by information provided by the nation's foremost experts on the delivery of high-quality and efficient health care -- family physicians.

    The AAFP has long advocated for payment models that appropriately value the care provided by family physicians. It has been and remains our opinion that payment levels for primary care services -- specifically evaluation and management (E/M) services -- have been undervalued throughout the history of the Medicare physician fee schedule. Undervaluation has had both immediate and long-term consequences, and the continued undervaluation of E/M codes negatively impacts the practices of family physicians and other primary care physicians.

    It is estimated that there are 10,000 CPT codes. Of those, E/M services are the most frequent services provided by physicians in the Medicare program, and primary care physicians provide the overwhelming majority of these services. Despite the fact that E/M services are the dominant services provided (both in terms of volume and frequency) in the Medicare program, those services have been dramatically undervalued monetarily for more than two decades.

    Despite this known fact, the office/outpatient E/M codes (99201-99215) were last reviewed by the AMA/Specialty Society Relative Value Scale Update Committee (RUC) in 2006 and revalued by CMS in 2007. With the exception of an adjustment made in 2010 as a result of CMS's decision to no longer recognize and pay for consultation codes, these E/M codes have not been reviewed or revalued since 2007. During the past 12 years, E/M codes have been passively devalued as the Medicare physician fee schedule has added new codes requiring budget neutrality adjustments to the rest of the fee schedule. Put more bluntly, each new code or revaluing of any of the existing codes results in a cut to E/M codes, further devaluing primary care services.

    Last summer, CMS proposed significant revisions to the Medicare physician fee schedule. Specifically, CMS proposed to collapse the new and existing patient E/M codes, creating a single code for current codes 99202-99205 and 99212-99215. These proposed changes alarmed the AAFP, and we communicated our concerns to CMS in a Sept. 5, 2018, letter.

    CMS ultimately chose to not implement its proposed changes to the fee schedule in 2019, but it plans to implement the consolidated payment levels for these codes in 2021.

    If CMS were to simply consolidate the E/M codes based on the current undervalued state of these codes, it would further devalue the core set of services provided by family physicians.

    A second factor that is motivating our accelerated advocacy is the development of primary care alternative payment models (APMs) and the role of E/M as the actuarial foundation of new payment models. Again, if primary care APMs are built on the current baseline value of E/M services, the models will further perpetuate the undervaluation of primary care.

    Although the proposed changes alarmed us, they also brought into focus that there is an opportunity to not only simplify coding and documentation as proposed by CMS, but also an opportunity to revalue the E/M codes that are most frequently used by family physicians. The revaluation of E/M services is imperative, and we may have an opportunity to change the baseline values of primary care services in 2019.

    Here's how: It is our belief that potential action taken by the Current Procedural Terminology (CPT) Editorial Panel this week, and subsequent action by the RUC in April, offer an immediate opportunity to have these codes reviewed and revalued by CMS.

    Should the CPT Editorial Panel and RUC not act in a timely fashion, the AAFP Board of Directors is prepared to ask CMS directly to review and revalue the codes in advance of any payment policy changes in 2021.

    This process will include an opportunity for each of you to contribute by providing valuable information that will help CMS determine the factual, accurate value of your services. In the coming weeks, you will be receiving information from the AAFP, including an email from President John Cullen, M.D., on how you can participate in this process and impact the future of family medicine. This is an opportunity that is worthy of your time, and we hope you will seize the opportunity.

    Teaching Health Centers

    If you follow this blog, you know that I am an unapologetic cheerleader for the Teaching Health Center Graduate Medical Education (THCGME) program. There are few public policies implemented in the past 10 years that have had a more positive impact on the future of our nation's health care system. There also are few policies that stand to significantly and immediately impact the family medicine workforce as much as the THCGME program during the next decade. Reauthorization and expansion of this program is a legislative priority for the AAFP in the 116th Congress.

    I am pleased to report that thanks to the AAFP's close work with our coalition partners, we have secured introduction of legislation to reauthorize the program. Last week, Sens. Susan Collins, R-Maine, and Doug Jones, D-Ala., introduced the Training the Next Generation of Primary Care Doctors Act, legislation that would reauthorize the THCGME program for five years and provide funding to support a modest expansion of new programs. Five years is not permanent, but it certainly is better than the instability we have experienced in recent years when the program was reauthorized for just two years, through September 2019.

    We need your help to secure enactment of this important legislation. I urge you to join our advocacy efforts by sending a letter to your U.S. senators using the AAFP Speak Out, urging them to co-sponsor and support the legislation.

    Family Medicine Advocacy Summit

    Each spring, the AAFP hosts the Family Medicine Advocacy Summit (FMAS) -- the largest annual advocacy event focused on the advancement of family medicine and the policy objectives of family physicians. The AAFP invites you to join us for the 2019 event May 20-21 in Washington, D.C.

    The first day of FMAS features a full schedule of policy and political updates from leading national experts, members of Congress and AAFP staff. On day two, participants will storm Capitol Hill to meet with their representatives and senators, carrying forward the policy priorities of the AAFP and family medicine.

    Register today and join us at the most exciting family medicine advocacy event of the year!

    FMAS will be held at the Marriott Marquis Hotel. The deadline for booking a room under the AAFP conference rate is April 20. Hotel reservations may be made online or by calling the hotel directly at (855) 821-4281. If you call the hotel, please be sure to reference the AAFP FMAS room block to receive the special conference rate.


    Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.  Read author bio »


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