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Update On The 2018 Evaluation And Management Proposed Rule Change

Most physicians/practitioners bill patient visits to payers using a set of codes known as evaluation and management (E/M) codes. Billing physicians/practitioners must maintain certain information in the medical record that documents the appropriate E/M codes have been reported.

The 2018 Final Rule for Revisions to Payment Policies under the Physician Fee Schedule has been published. Prior to publishing the Final Rule (Proposed Rule), CMS was seeking feedback and giving consideration to changing the current E/M guidelines, which have been in place since 1995 and 1997. Although the Proposed Rule did not become Final for 2018, CMS agrees with continued feedback from stakeholders that the guidelines are potentially outdated and need to be revised.

Current E/M Guidelines

The current E/M guidelines direct that a level of service is based on three components of documentation, with medical necessity being the overarching criteria.

    • History of Present Illness (History)
    • Physical Examination (Exam); and
    • Medical Decision Making (MDM)

The above components are used to build the level of service; however, with the implementation of the electronic health record (EHR) it has become easier to base a level of service on the History and Exam; with less consideration given to the MDM and medical necessity.

Proposed Change Still Being Considered

CMS is proposing to bill a level of service based on MDM and medical necessity; rather than all three components. The History and Exam will still be required documentation, however, the reported E/M code level will be relative to “why did the patient come in today”; “what are we doing to treat the patient today”.

Had the Proposed Rule become Final (or if it does in the future), we can possibly see an impact to RVU’s; an impact to reimbursement; reduced clinician burden; and improved meaningful documentation.

What can we do if the Proposed Rule becomes Final in the future?

Whether the Proposed Rule becomes Final in the future or not, Blue & Co. is available to assist our clients in ensuring the documentation in the medical record supports the E/M level of service reported. We can:

  • Perform a bell curve analysis
  • Perform a documentation analysis
  • Provide documentation improvement education
  • Assist in EHR template builds

Although the Proposed Rule did not become Final for 2018, the above services are currently very beneficial to any organization to ensure the physicians/practitioners are reporting current E/M services appropriately.

If you have questions or would like to know more about Evaluation and Management services, please contact Heather Reagan, hreagan@blueandco.com, or give us a call.

 

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