As 2018 drew to a close, the AAFP supplied detailed comments to CMS regarding final rules and an interim final rule that will affect Medicare payment -- specifically, revisions to payment policies that apply to the 2019 Medicare physician fee schedule and other revisions to Medicare Part B.
The rules were published in the Nov. 23 Federal Register.(www.govinfo.gov)
In a Dec. 28 letter(12 page PDF) to CMS Administrator Seema Verma, M.P.H., that was signed by AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan., the AAFP opened by expressing appreciation for CMS' support for primary care in recent years.
"The AAFP appreciates that CMS recognizes the problems with the current E/M (evaluation and management) documentation guidelines and codes" and that the agency is intent on addressing them, said the letter.
"Since CMS has publicly stated that the document that outlines E/M documentation guidelines is not owned or maintained by the agency, the AAFP is further encouraged that Medicare can now fully divorce itself from using these documents for auditing and payment purposes," said the AAFP.
The AAFP devoted a good portion of the letter to recommendations regarding physician payment for work related to providing E/M visits to patients; the letter explored Academy concerns about documentation relief, payment policies and add-on codes.
The AAFP noted its appreciation that CMS planned to implement some immediate documentation relief related to E/M services, such as the opportunity for physicians to rely on relevant information already in the medical record for established patients -- a decision that will "allow family physicians to focus their documentation on what has changed since the last visit … and avoid re-recording certain elements just for the sake of meeting outdated documentation guidelines."
- In a recent letter to CMS, the AAFP outlined avenues for the agency to explore that would support fair payment to primary care physicians who provide health care services to Medicare patients.
- The letter focused on CMS changes to documentation and payment related to evaluation and management (E/M) services.
- The Academy made recommendations related to documentation relief for physicians, the collapsing of E/M codes 99212-99214 and the implementation of add-on codes.
Additionally, said the letter, "We hope this natural experiment will reinforce CMS' intent to provide additional documentation relief in 2021."
The AAFP also detailed its support for CMS' plan to to let physicians choose -- as an alternative to the current documentation framework specified by 1995 or 1997 guidelines -- either medical decision-making or time for determining the appropriate level of an E/M visit.
"Pending the work of the CPT Editorial Panel in 2019, we believe CMS should implement this plan in 2020 and without regard to its planned single payment amount for levels two through four of the office/outpatient visit codes," said the AAFP.
The AAFP also encouraged CMS to work with the CPT Editorial Panel and other stakeholders to develop a "single set of E/M documentation guidelines that can be used by all physicians and payers," because accomplishing this task would signify a major step toward administrative simplification for family physicians and other frequent users of E/M codes.
The AAFP lauded CMS' decision "not to proceed (until 2021) with its proposal to collapse the payment rate for office/outpatient visits levels two through five."
Furthermore, after additional analysis, the AAFP determined that CMS' proposed $90 value for the collapsed 99212-99214 codes "would result in a net-negative impact on family medicine and would further perpetuate the undervaluation of primary care.
"We cannot support this proposal as a stand-alone policy," said the AAFP.
The Academy went on to say it would continue to recommend adding a 15 percent increase to the proposed collapsed code and the 99215 code for billings by primary care physicians as "a more appropriate mechanism for achieving our shared goal of improving the value of primary care."
The letter pointed out that CMS' planned payment levels (combining E/M visit levels two through four and maintaining level five coding and payment) would create negative consequences. For instance, Medicare patients will pay more out of pocket for level two and level three visits, and physicians who continue to address multiple problems at a given encounter, rather than ask patients to return for additional visits, will be penalized financially.
"This disruption in continuity and comprehensiveness is the foundation of our concerns," said the AAFP. This payment policy, if implemented in 2021, "will incentivize more frequent visits that are shorter in duration and limited in scope."
"In short, we worry that CMS' plan could place an even greater emphasis on episodic care of discrete conditions that creates pressure to stint on care at an office/outpatient visit and churn patients. This scenario is contrary to the tenets of family medicine, which emphasize continuous, comprehensive care of patients."
The AAFP recommended CMS invest in a small-scale demonstration project on any payment revision before implementing anything nationwide.
Even as the AAFP noted its appreciation to CMS for its intention to include add-on codes -- due for implementation in 2021 -- that value primary care services at a level equal to the code for nonprocedural specialty visits, the letter reminded the agency that the AAFP already had offered a better solution.
"We continue to believe CMS should eliminate the primary care add-on code and replace it with a 15 percent increase in payment for E/M services provided by physicians who list their primary practice designation as family medicine, internal medicine, pediatrics or geriatrics," said the AAFP.
The letter also expressed concern that CMS' primary care add-on code would be available to physicians practicing in nonprimary care specialties.
Physicians who are not trained in the primary care specialties listed above "may provide some primary care 'services' that are similar to those usually delivered by primary care physicians -- but this does not constitute primary care," said the AAFP.
The letter called on CMS to redefine code GPC1X to ensure it only covers visit complexity "inherent to evaluation and management associated with primary medical care services provided by family physicians, general internists and general pediatricians, as well as other qualified health care professions who work with them, who offer comprehensive first contact and/or continuing care for the undifferentiated patient not limited by problem origin, organ system or diagnosis, and who serve as the continuing focal point for all needed health care services."
The AAFP covered additional areas in its comments and suggestions to CMS on how to improve the rules moving forward.
For instance, the letter touched on
- certain services furnished by opioid treatment programs and recommended that services include coordination with primary care physicians;
- the clinical laboratory fee schedule and the AAFP's call for CMS to "work with Congress to address inadequate and decreasing Medicare payments to in-office laboratories;"
- appropriate use criteria (AUC) for advanced diagnostic imaging services and the AAFP's strong request that CMS "exempt all primary care physicians participating in the QPP (Quality Payment Program) from AUC requirements;" and
- updates to the QPP program, including concern about the "all or nothing" nature of the promoting interoperability category and performance measurement across categories.
Related AAFP News Coverage
Review AAFP Summary of 2019 Medicare Physician Fee Schedule
Get Need-to-Know Details That Affect Family Physicians