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OAR Action Alert: Tell CMS to Reject E/M Payment Changes in 2019 Proposed Physician Fee Schedule

posted: August 29, 2018

As part of the 2019 Physician Fee Schedule, CMS is proposing a number of documentation and payment changes for evaluation and management (E/M) visits that if implemented, would have a major impact on rheumatologists and their practices, and could significantly reduce access to high quality care for rheumatology patients across the country.

Most significantly, CMS is proposing to apply a single blended payment rate for level 2 through 5 office and outpatient E/M visits for both new and established patients. This proposal would apply a single payment rate for level 2 through 5 visits for new patients and a separate single payment rate for established patients.

The proposal would also implement a 50% payment reduction for the least expensive procedure or E/M visit that is provided on the same day, currently identified on the claim by an appended modifier -25. This means that under the new payment structure, rheumatologists that furnish E/M visits to patients on the same day as their injection or infusion will be forced to make the patient schedule an appointment and come back on a different day for their E/M visit in order to avoid such a significant reduction in reimbursement.

Given its potential impact on rheumatologists, OAR is calling on its members to make your voices heard and submit comments to CMS expressing your opposition to the proposed changes to E/M visits and urging the agency to reconsider its E/M payment proposal before it is finalized. OAR has provided talking points and general form letter below for you to use in crafting your own personalized comments.

How to Submit Comments to CMS

Comments on proposed rules are submitted via regulations.gov.  To submit comments to CMS, please click here and fill out the required submission form. You can copy and paste your comments in the provided section labeled comment (first box), or you can attach your comments as a separate PDF or Word document by uploading the appropriate file. Please note that the comment section is required, so if you upload your comment as a separate file, please copy and paste the below text into the comment field.

As a practicing rheumatologist and member of the Ohio Association of Rheumatology, I respectfully submit the attached comments on the 2019 physician fee schedule and QPP proposed rule (CMS-1693-P).

Sample Form Letter

Dear Administrator Verma,

As a practicing rheumatologist in <city, state> and a member of the Ohio Association of Rheumatology, I am writing to express my opposition to the proposed changes for evaluation and management (E/M) services included in the proposed 2019 Physician Fee Schedule. As it is currently written, the payment proposal for E/M visits would have a significant negative impact on rheumatologists, and ultimately would significantly reduce access to high quality care for rheumatology patients across the country.

The proposed single payment rates for E/M visits will adversely affect patients with complex problems, which are commonly seen by rheumatologists. Patients with autoimmune and inflammatory diseases like lupus and rheumatoid arthritis are often complicated and require comprehensive care. Under the payment proposal, physicians who see more level 4 and 5 patients will see a potentially significant reduction in their reimbursement for E/M services, which are already undervalued relative to other physician services.

The proposal would also implement a 50% payment reduction for the least expensive procedure or E/M visit that is provided on the same day, currently identified on the claim by an appended modifier -25. This means that under the new payment structure, rheumatologists that furnish E/M visits to patients on the same day as their injection or infusion will not be able to do so in order to avoid a significant reduction in reimbursement. Patients will have to make two separate visits, which complicates scheduling and diminishes access to care.

<Discuss what this reduction would mean for you and your practice, and provide example of what that would mean for your patients.>

As such, I urge CMS to reconsider its payment proposal for E/M visits and not adopt it in its current form.

Additional Talking Points:

  • Physicians are experiencing significantly decreased reimbursements while overhead continues to rise.
  • Some physicians are limiting the number of Medicare patients or no longer seeing Medicare patients because of diminished reimbursements. This exacerbates patients’ access problems.
  • Reimbursements for infusion codes have already been decreased.
  • There is already a shortage of rheumatologists and decreasing reimbursements on E/M codes will discourage residents from pursuing a career in rheumatology or other cognitive specialties.
  • Rheumatologists will be forced to see a larger volume of patients in order to keep reimbursement the same, which will inevitably decrease face to face time with individual patients.