Community Oncologists Say Proposed CMS Updates to E/M Services Undermine Patient Care

A proposed 2019 rule change for services furnished under the Medicare Physician Fee Schedule (MPFS) is not going down well with oncologists. In July, the Centers for Medicare & Medicaid Services (CMS) issued the proposed change that would lower some payments for patient evaluation and maintenance (E/M) services.¹

CMS described the changes as a way to cut down on administrative needs that keep physicians from spending more time with their patients. For example, coding requirements for billing would be simplified under the proposal.

The Community Oncology Alliance (COA) provided a rebuttal, contending that the proposed changes would do little to reduce paperwork and could instead significantly hurt the quality of patient care and practice operations. “CMS tends to ignore the requirements for comprehensive care,” said Bo Gamble, director of strategic practice initiatives for COA, in an interview with Targeted Therapies in Oncology.

Documentation actually improves the quality of care, Gamble said: “Documentation reflects the effort that has been taken for the patient. This documentation is then shared with other physicians so there is continuity and consistency.”

Not all agree that there is no room for documentation reduction in oncology care. “The goal of these changes is to try to improve the efficiency of the medical practice, which is certainly something that is good for all oncologists,” said Akiva P. Novetsky, MD, MS, in an interview with Targeted Therapies in Oncology. “The amount of documentation that is required for the current E/M services leads to a significant degree of inefficiency.” Novetsky is a gynecologic oncologist and chief quality officer at Rutgers Cancer Institute of New Jersey in New Brunswick.

The current guidelines organize MPFS payment rates for E/M services into various levels based on patient history, the physical exam, and medical decision making or face-to-face time with the patient. More complex visits correlate with higher code levels and payments.

The proposal would simplify documentation requirements by reducing payment codes for E/M visits from 5 to 2 for both new and established patients. The proposed change substantially reduces the maximum E/M fees that could be billed. Additionally, providers would be able to choose either medical-decision making or face-to-face time as the sole basis for the appropriate level of E/M visit.

Novetsky expressed concern that these revisions could negatively affect patients with more complex diseases. “For patients who are particularly complex, there may be a disincentive for physicians to take care of them because of the amount of time that they will need to spend with the patients, as well as coordinating their care, with potentially lower reimbursing rates,” he said.

CMS has stated that these changes would reduce the amount of work and deliberation it takes for providers to document the correct visit level, enabling physicians to spend more time with patients, but COA disagrees. “This undermines the value component of [patient care],” Gamble said. “In this case, they threw all patients into the same bucket.”

The American Society of Clinical Oncology (ASCO) also issued a strong objection to the proposed changes, contending that they would reduce resources available to provide patients with high-quality care: “ASCO believes the cuts in the 2019 proposed MPFS rule will harm Medicare beneficiaries with cancer and impede the ability of oncologists to provide the right treatment, to the right patient, at the right time. We urge CMS to abandon this proposal and support robust access to cancer care.”

In a formal letter to CMS administrator Seema Verma, COA stated that the revisions would negatively affect providers, particularly oncologists, who see more complex patients. Results from a survey commissioned by COA showed that 65% of current E/M services provided by oncologists are code levels 4 and 5 compared with 54% for general practice. Under the proposed changes, oncologists would earn less for code 4/5 billing.

“COA estimates that the total impact of the proposed changes to E/M services billed by community oncology would be an almost 11% reduction, or approximately an $84 million reimbursement cut across all community oncologists billing in the physician office setting,” the letter stated.

For level 4 and 5 visits with established patients, providers would see a compensation reduction from $109 and $148, respectively, to $93, with the newly proposed rate. An even greater decrease is expected for new patients based on the 2019 proposed relative value units—which Medicare uses to calculate physician reimbursement based on practice expenses, the amount of physician work required for a given procedure, and more—and based on the current 2018 MPFS payment rate. On the other hand, payments for the lowest-level visits will see an increase from $22 to $24. Payments for levels 3 and 4 will rise to $93 from $45 and $74, respectively.²

The proposal addresses the imbalance by including a series of add-on codes that recognize additional resources needed for more complex E/M visits. For example, Medicare will provide a designated add-on payment for every 30 minutes an E/M visit is prolonged. The proposed rule change does not spell out the criteria for billing for additional time, however.

COA also suggested that the use of a time-based add-on code would place too much importance on the length of a visit, rather than the quality of MDM. “Providers should be able to focus on providing their patients attentive care without having to worry about starting and stopping the clock to receive payment,” COA said. “This proposal appears to be another example of valuing quantity of care over quality of care.”

Although Novetsky does not agree with consolidating E/M visit levels, he does agree with the initiative to decrease administrative burden. “I don’t believe that documentation is a good surrogate for quality outcomes,” he said. “Providing new opportunities and participating in quality improvement projects will not decrease the quality of care through less charting.

References:

1. Proposed policy, payment, and quality provisions changes to the Medicare physician fee schedule for calendar year 2019 [press release]. Baltimore, MD: CMS; July 12, 2018. cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-3. Accessed October 22, 2018.
2. Calendar year (CY) 2019 Medicare physician fee schedule (PFS) proposed rule: documentation requirements and payment for evaluation and management (E/M) visits & advancing virtual care. CMS website. cms.gov/About- CMS/Story-Page/2019-Medicare-PFS-proposed-rule-slides.pdf. Accessed October 26, 2018.