WASHINGTON -- With great fanfare, officials at the Centers for Medicare & Medicaid Services (CMS) on Thursday announced a number of proposed initiatives in the that they say will ease administrative burdens on providers.
"I spent part of the last year traveling the country and visiting clinicians in different care settings," CMS administrator Seema Verma said on a conference call with reporters. "One thing we heard time and time again is that time spent on paperwork is time away from patients ... We heard too many stories about provider burnout. It became clear to me that if we were going to be serious about improving quality and access for patients, we have to improve the lives of providers on the front lines."
More E/M Documentation Options
One example of this push is several proposed documentation changes aimed at cutting the burden on physicians who provide evaluation and management (E/M) services. These include giving providers the following options:
- Documenting office/outpatient E/M visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation guidelines
- Using time as the governing factor in selecting visit level and documenting the E/M visit, even if counseling or care coordination dominates the visit
- Focusing documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided the physician reviews and updates the previous information
- Reviewing and verifying certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it
CMS is also proposing to streamline the E/M coding system itself by having "new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services," the agency said in a posted on its website.
This change includes a "minimum documentation standard" for a level 2 visit "where Medicare would require information to support a level 2 CPT visit code for history, exam and/or medical decision-making in cases where practitioners choose to use the current framework, or, as proposed, medical decision-making to document E/M level 2 through 5 visits," CMS said.
"In cases where practitioners choose to use time to document E/M visits, we propose to require practitioners 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," the fact sheet continued. Although physicians might want to include additional information for clinical or legal reasons, "we would only require documentation to support the medical necessity of the visit and associated with the current level 2 CPT visit code."
The agency estimated that making these changes to E/M coding will save providers 51 hours per year, an amount that Verma said was "one of the most significant reductions in provider burden undertaken by any administration."
Changes in Part B Drug Payments
The agency also is proposing to change the way it pays for new drugs that physicians administer under Part B of the Medicare program. Under the current system, during the first two quarters that a new drug is on the market, Medicare pays the physician the drug's wholesale acquisition cost (WAC) plus a 6% fee to cover office overhead and the cost of administration. CMS is proposing to cut the payment to WAC plus 3%, "so the payment amount more closely matches the actual cost of the drug," Verma said.
After the first two quarters, reimbursement for the new drug would revert to the current system, which pays doctors the average sales price of the drug plus an additional 6%.
CMS also is proposing changes to Medicare's Merit-Based Incentive Payment System (MIPS), which is used by physicians who aren't participating in an advanced payment model such as an accountable care organization. The MIPS program requires providers to submit data on six quality measures of their choice. "We're proposing to remove process-based measures [from MIPS]," Verma said. "Many of these measures are 'topped out'" -- that is, almost all providers are reporting that they're doing very well on them.
"We've heard from doctors that using these measures is really just measuring processes and doesn't focus on improving patient outcomes," she continued. CMS's proposal "would remove 34 measures from the program immediately while continuing to focus on patient safety, saving providers collectively an estimated 26,313 hours, or more than $2.3 million in 2019."
On the advanced payment model side, CMS is seeking to drop 10 measures for accountable care organizations "that aren't driving toward improved quality," Verma added.
Increasing Telemedicine Use
The agency also is trying to increase the use of telemedicine. "Under this proposal, Medicare will start paying for virtual check-ins, meaning patients can connect with their doctor by phone or video chat," she said. "Many times [that will] get them the care they need and avoid unnecessary costs in the system. This is not intending to replace office visits, but rather to augment them and create new access points for patients." The proposed rule also would allow for payment when the doctor reviews an image that a patient texts to the office.
One area that Verma did not discuss on the call was the overall percentage increase in the amount that Medicare was reimbursing physicians. Last year, Medicare increased overall payments to physicians by 0.41%. This year, payments will increase by $0.3 billion -- that includes a 0.25% increase as mandated in this year's Bipartisan Budget Act, minus 0.12 percentage points to account for some changes in relative value units.
The proposed rule also lists the fee schedule's final conversion factor -- the amount that Medicare's relative value units are multiplied by to arrive at a reimbursement for a particular service or procedure under Medicare's fee-for-service system. That figure is $36.05, up slightly from last year's conversion factor of $35.99.