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November 14, 2018


CMS Issues Final Rule on E/M Codes

The Centers for Medicare & Medicaid Services issued a final rule on Nov. 2 on proposed changes that would dramatically alter the Outpatient Evaluation & Management (E/M) codes. The following summarizes the changes included in the final rule that CMS will implement:

  • For Calendar Year 2019, CMS is finalizing several policies that reduce documentation requirements for E/M visits.  The specific policies affected can be found here.
  • In CY 2021, CMS will create a single payment rate for levels 2 - 4 E/M outpatient visits (one rate for new, and one for established patients) and maintain separate payment rates for new and established patients for level 5 E/M office/outpatient visits to account for the most complex patients and visits.
  • In CY 2021, CMS will finalize payment rates for levels 2 - 4 visits using the weighted average of the current inputs (work RVUs, direct PE inputs, time and specialty mix) assigned to the individual codes, based on the most recent 5 years of utilization for each of the constituent codes.
  • A summary table of the E/M coding and payment changes that will go into effect in CY 2021 can be found here.

Since ID physicians bill a significant proportion of their outpatient encounters as Level 4 or 5, IDSA is pleased that CMS has left intact the coding and payment rate for a Level 5 encounter. However, we are concerned with the 22 percent payment reduction for a Level 4 new patient visit and the 17 percent payment reduction for a Level 4 existing patient visit.  The rule also allows ID physicians and some other specialists to utilize a new “complexity adjuster” though it is not yet clear to what extent this may mitigate some of the cuts to Level 4 payments or otherwise impact reimbursement. 

In coordination with other medical societies, IDSA is in the process of assessing the financial impact this will have on the specialty. More importantly, IDSA will be engaging congressional stakeholders to continue urging CMS to appropriately value E/M services.  This is where your help is vitally needed.  Please visit the IDSA Advocacy Action Center and send a message to your elected officials in Congress, letting them know of the negative impact inadequate reimbursement has on your practice, your patients, and the future of the ID workforce. Such constituent messages are the most impactful advocacy tools we can employ and are more likely to lead to action.  


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