AAFP Makes Case for New Primary Care E/M Codes

Letter, Supporting Research Materials Delivered to CMS

April 05, 2013 12:50 am Sheri Porter

The AAFP recently put in writing a recommendation that CMS create, in a timely fashion, new evaluation and management (E/M) codes exclusively for primary care physicians.

[Senior man sitting at table talking to doctor]

In the March 27 letter with supporting documentation(43 page PDF) to CMS Acting Principal Deputy Administrator Jonathan Blum, the AAFP noted that the correspondence was a follow-up to a March 7 meeting in Washington, during which representatives from the AAFP and CMS discussed payment for primary care services.

"The AAFP recommends that CMS create, as part of the 2014 Medicare physician fee schedule, separate primary care E/M Healthcare Common Procedure Coding Systems codes for office or other outpatient services to new and established patients with correspondingly higher relative values to address this issue," wrote AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash.

Story Highlights
  • In a recent letter to CMS, the AAFP asked the agency to create new evaluation and management codes exclusively for primary care physicians. 
  • The AAFP requested that the new codes be included in the 2014 proposed Medicare physician fee schedule due out in July. 
  • The AAFP backed up its recommendation for new codes with detailed supporting documents and research conducted by an outside consulting firm.

If the country wants to achieve the goals of better health care for individuals, better health for populations and lower per-capita health care costs, a new payment model is necessary, said Stream. "That system should recognize the complexity of ambulatory care provided by primary care physicians and reward the quality of services provided in their practices."

He noted that by CMS' own admission, the standard fee-for-service payment methodology likely would remain the primary Medicare payment model in the foreseeable future, despite widespread testing of new and promising payment models. "Failure to correct the flaws in the fee-for-service system as they relate to primary care is only likely to perpetuate those flaws in new payment models," that rely on the current system as a benchmark, said Stream.

He pointed out that the intensity and complexity of an office E/M encounter with a primary care physician was quite different from that of such encounters with other specialists or subspecialists. Primary care physicians strive to deliver "continuous care that includes treatment of illness before symptomatic presentation, extensive screening and prevention, counseling, and, increasingly, other social services," said Stream.

On the other hand, nonprimary care physicians most often address only the presenting patient concern. The current method of coding for E/M services across specialties exacerbates the issue of inadequate payment for primary care. "Combining all E/M encounters together … undervalues primary care and overvalues other types of care," said Stream.

He acknowledged the "operational issues" that come with the creation and valuation of new primary care E/M codes. As a starting point for addressing those issues, Stream referenced AAFP definitions of terms such as primary care, primary care physician and nonprimary care physicians providing primary care services.

"In particular, we believe that eligibility requirements related to these new codes should reward physicians trained in primary care," said Stream. Additionally, primary care physicians should be able to demonstrate that they are carrying out three "definitional functions of primary care," -- first contact with the patient, continuity of care and comprehensiveness of care -- all of which can be ascertained by reviewing claims data.

Stream conceded another operational hurdle CMS would have to overcome: budget neutrality. "On this issue, the AAFP supports making the budget-neutrality adjustment to the conversion factor so the impact is spread across the entire Medicare physician fee schedule," said Stream.

He asked CMS to make use of the information provided in a position paper and appendix that accompanied the letter to "move ahead" with creating and valuing, as part of the 2014 Medicare physician fee schedule, the codes the AAFP requested.

"We are willing and ready to work with CMS on any operational aspects of our recommendation," said Stream.

In a separate interview with AAFP News Now, Stream said the March 27 letter was the culmination of a series of steps the AAFP had taken since 2011 -- at the behest of family physician members across the country -- to increase payment for primary care services.

"Family physicians want to provide high-quality care for their patients and, in particular, those patients with multiple chronic diseases who require higher levels of care management and coordination," said Stream. "But we can't continue to do the work our patients require without appropriate payment that recognizes the complexity and intensity of current primary care practice."

The Academy charted a new course in the search of primary care payment solutions in July 2011 with the creation of the Primary Care Valuation Task Force, said Stream. In 2012, that task force released recommendations that included calling for primary care-specific codes.

The AAFP's decision in 2012 to continue its participation in the AMA/Specialty Society Relative Value Scale Update Committee (RUC) was difficult, but necessary, said Stream. "However, we made it clear to the RUC that we intended to appeal directly to CMS for more equitable payment mechanisms, and we have done so," he said.

"Our collaboration with outside experts during the course of the past year resulted in the development of good hard data that strengthened the case for primary care that we presented to CMS," said Stream.

Stream urged members to stay positive and stay tuned in. "I'm not sure how CMS will respond to our latest effort, but I assure you that the AAFP will keep pushing for fair payment because it's critical to the health of our patients, our practices and our specialty," he said.