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Bold Proposed Rule for the 2019 Medicare Physician Fee Schedule: Can Physicians Afford to Abandon Documentation Burdens?

The proposed rule for the 2019 Medicare Physician Fee Schedule contains a bold proposal to eliminate mandated documentation guidelines for outpatient evaluation and management services in exchange for a flat, fixed payment rate and relief from audit burdens (1, 2). The physician work relative value units would remain the same for Current Procedural Terminology (CPT) codes 99201 to 99205 and 99211 to 99215 (1, 2). To justify reporting a particular CPT code in their office note, physicians would have several options. They could use the current guidelines, which range from the minimal documentation required for CPT code 99212 to the complete physical examination and highly complex medical decision making required to report CPT code 99215. Alternatively, they could document just their medical decision making and relevant elements of the history or physical examination or choose a CPT code based solely on face-to-face time with the patient (1, 2). Regardless of the choice of CPT code and documentation, the provider would receive the same payment and, consequently, relief from audit burdens (Table). Table. Outpatient Office Services This proposal represents the culmination of more than 20 years of discussion. Physicians vocally objected to the initial presentation of the documentation guidelines in 1995, their implementation in 1996, and the option of single-system physical examinations in 1997 (3). The guidelines contribute to bloat of and frustration over electronic health records (EHRs) (4, 5). Over the decades, many alternatives were considered, including using clinical vignettes for standard settings or choosing a CPT code based on face-to-face time or medical decision making. None of these were considered viable, and the wasteful infrastructure of audits, physician intimidation, and ballooning EHRs burgeoned (5, 6). Many argued that the differential burden of the documentation guidelines on primary care and other nonprocedural physicians exacerbated interspecialty inequities in physician reimbursement and contributed to physician dissatisfaction, burnout, and disdain for primary care and nonprocedural careers (6, 7). Analysis of the proposed rule that is based on current billing patterns reveals that different specialties would experience increases, decreases, or little change in overall reimbursement (1). Large multispecialty groups will likely be able to offset decreases in reimbursements for some specialties with increases in others. The large percentage of revenue derived from a fixed payment per beneficiary would protect primary care groups participating in Comprehensive Primary Care Plus. However, such analysis misses the opportunity offered by this proposal. Shedding the documentation burden in exchange for a flat, fixed payment rate would offer new opportunities to report meaningful, newly reimbursable primary and specialty care services; complex patient care; and additional care coordination activities (Table) (1). These newly reimbursable services extend the commitment of the Centers for Medicare & Medicaid Services (CMS) to identify and compensate physicians for the services they actually provide to patients as an intermediate step toward shifting physician payments to value-based and bundled services (8). The future financial viability of small or solo practices or large multispecialty groups will depend on garnering reimbursements for such services. In addition to changing the way they deliver care, primary care and nonprocedural physicians will need to change the way they are reimbursed for it. This will require adopting new workflows, shifting from fulfilling documentation requirements with cloned notes to effective care coordination and meaningful clinical documentation, and increasing nonface-to-face care and electronic communications (4). Coupling reimbursement for these newly recognized services with existing CPT codes should provide enhanced revenues for practices offering modern, patient-focused care. Implementation of the proposal will require little change from EHR vendors, and the current complement of documentation tools will still be necessary for inpatient services. However, eliminating outpatient documentation guidelines would enable EHR vendors to focus on enhancing usability in the outpatient setting and trading bloated notes for meaningful documentation (46). If CMS implements the proposed rule in January 2019, physicians may not immediately change their documentation patterns, especially if they care for a largely non-Medicare population. Non-Medicare payers will need time to consider and implement (through contracting) similar elimination of the documentation guidelines. Both Medicare Advantage plans and state-regulated Medicaid programs heavily audit physicians for their office visit CPT codes and may continue to require physicians to document according to the old guidelines. The proposed rule may have unintended adverse consequences. Because of the fixed payment, physicians may choose to see patients more frequently or avoid complex patients. Alternatively, they may send sick or complex patients to emergency departments rather than providing nonface-to-face or office-based care. However, the combination of new and existing CPT codes for complex patient care, care coordination activities, nonface-to-face activities, and electronic communications promises to provide appropriate reimbursement to physicians caring for such high-intensity patients. We recommend that both CMS and the physician community proceed, but with caution. The proposed rule is open for public comment until 10 September 2018 at www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. Comments should emphasize that the proposed G code values for primary care and complex patients (Table) are too low and should demand redefinition and revaluation of these codes to ensure appropriate reimbursement for all physicians providing primary care or caring for complex patients. Other aspects of the rule, including application of a multiple-procedure payment reduction for an office visit and a procedure, are inappropriate because overlapping elements of physician work and practice expenses have already been eliminated in recent years from CPT codes typically reported together. The elimination of documentation guidelines as fodder for audits should not be exchanged for new audits of medical necessity or visit frequency. Rather, their elimination should serve to remove auditors from the examination room, where they are interposed between physician and patient. The proposed rule requires time for CMS and medical societies to educate physicians; physicians to change workflows, modify care delivery, and improve documentation; and other payers to follow in a coordinated manner. Delaying implementation until January 2020 would allow time for this bold proposal to achieve success rather than creating crisis.