Healthmonix Advisor

The Small Change To E&M Charges That Could Hugely Impact Your Reimbursement

Posted by Christopher Jayne on August 23, 2018
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The new proposed rule for 2019 features a lot of changes to the Quality Payment Program, but CMS has also announced changes impacting Medicare reimbursement in general. One big change proposed would affect how much money a clinician receives for billing office or outpatient Evaluation and Management (E&M) visits for new and existing patients.

Payment Level Compression

In the past, those E&M CPT codes (99201-99205 for new patients or 99211-99215 for established patients) carried tiered payments rates from levels 1 through 5. Essentially, CMS compressed the different pay rates from a five-tier scale into a two-tier scale for these codes, meaning that billing a level 2 or level 5 visit would each provide the same payment from Medicare.

Clinicians who bill a large proportion of level 2 encounters will find that they are receiving more in payments for the same visits under this change. Clinicians billing a higher proportion of level 4 or 5 encounters are going to see that their payments will be smaller. The compression of those payment levels is shown below.


E&M Visit Level Current Payment Rate (New patient) Proposed Payment Rate (New Patient) Current Payment Rate (Established Patient) Proposed Payment Rate (Established Patient)
Level 1 $45 $44 $22 $24
Level 2 $76  $135 $45   $93
Level 3 $110 $74 
Level 4 $167 $109 
Level 5 $211  $148


Why the changes?

CMS does explain the reason for these changes. There are quite a few nuances on that page, but the overall goal is to simplify the process for charging E&M visits in the hope of reducing redundancy and bringing focus back to care of patient. They propose allowing clinicians to choose time or medical decision-making to document E&M visits in lieu of the current E&M framework set by the 1995 & 1997 guidelines.

CMS also is proposing the addition of G Codes to address complex patients and ensure that those providers billing a high number of Level 4 or 5 encounters are fairly compensated. The goal is that this flexibility can offset any significant payment shifts.


Make your voice heard!

We highly recommend you consult the proposed rule and comment on this suggested change. This change may have been overshadowed by the MIPS and APM framework released, but feedback will serve to improve the existing process and inform any future changes.

RELATED: How To Comment on the 2019 Proposed Rule



Topics: MACRA & MIPS, Policy, ROI