Buying Time: Medicine’s Warnings Prompt CMS to Delay Dramatic Coding and Payment Changes
By Joey Berlin Texas Medicine January 2019


The chorus was loud, broad, and adamant. And for now, it helped avert disaster.

Houston physical medicine and rehabilitation resident Ellia Ciammaichella, DO, was a member of that chorus when the Centers for Medicare & Medicaid Services (CMS) proposed dramatic changes to its 2019 physician fee schedule. Medicine howled, flooding CMS with written objections. (See “Cornered,” October 2018 Texas Medicine, pages 20-25,

Dr. Ciammaichella fired off a comment to CMS in August contesting its proposal to combine and effectively reduce payment for the various levels of evaluation and management (E&M) coding for outpatient office visits, a move that the Texas Medical Association warned would disincentivize caring for complex patients. Those are the type of patients Dr. Ciammaichella sees all the time.

“In fact, they will come in complaining of one thing and there’s actually something completely different that’s wrong with them, and we spend a good amount of time with them,” said Dr. Ciammaichella, a resident and fellow section appointee to TMA’s Council on Health Care Quality. “It would just make us have to bring in the patient multiple times, which is very hard for them, because they have impaired mobility and difficulty getting to the clinic as it is.”

She also objected — as TMA did — to a CMS-proposed payment reduction tied to E&M office visits and procedures billed on the same day.

But when CMS issued the final fee schedule, the agency showed it had heard Dr. Ciammaichella, TMA, the American Medical Association, and many other protesters. Those worried voices gave way to deep exhales when CMS announced it was delaying overhaul of the E&M codes until 2021. More encouraging for medicine, CMS said the delay will “allow for continued stakeholder engagement” on the topic. 

As for the “multiple procedure payment reduction” for office visits and procedures on the same day, CMS ditched that proposal entirely.

While the final fee schedule isn’t a completely joyous document for physicians to lay eyes on, avoiding those changes were resounding near-term victories.

“I think it really shows that the advocacy of all the different medical groups, from TMA, AMA, as well as specialty groups, [has] really made an impact,” Dr. Ciammaichella said. “I think that CMS did listen to us.”

Catastrophe averted

Little Elm internist John Flores, MD, chair of TMA’s Council on Socioeconomics, says the rules for this year are navigable for physicians who take Medicare patients.

Much to medicine’s momentary relief, the outpatient office visit structure for both new and established patients stays the same in 2019 and 2020: Five levels of E&M coding and payment. Physicians still should use either the 1995 or 1997 E&M documentation guidelines, CMS says.

In publishing the rule, CMS said it was “sensitive to commenters’ suggestions that we should consider a multi-year process and proceed cautiously, allowing adequate time to educate practitioners and their staff; and to transition clinical workflows, EHR templates, institutional processes and policies, … and other aspects of practitioner work that would be impacted by these policy changes.”

Maintaining the status quo for the next two years is “a huge win,” Dr. Flores says. And the 2019-2020 rules include improvements to reduce physician documentation burdens — something CMS promised and TMA supported during the rulemaking process. Among the key changes in the final rule:

• Home visits no longer require documenting the medical necessity of visiting the patient at home as opposed to an office visit;

• A patient’s history and examin-ation no longer must be re-documented if the same information is already in the medical record. The physician must document only changes;

• Physicians are no longer required to re-enter information on a patient’s chief complaint and history in the medical record if ancillary staff or the patient has already entered that information. Physicians must indicate simply that they reviewed and verified the information already there.

Dr. Flores praised those changes, in particular getting rid of redundant documentation on patients’ illness history.

“That’s a good step forward,” he said, adding that modern electronic health records already make some elements of documentation less onerous than they used to be.

Another key change now in effect: Clinical staff are allowed to perform consultations on whether planned advance diagnostic imaging services qualify for payment under Medicare’s appropriate use criteria (AUC). The “ordering professional,” such as the physician, can “exercise their discretion” to delegate an AUC consultation to staff, CMS says.

More work to do before 2021

However, many of the concerns medicine had with the initial 2019 fee schedule proposal remain as long as CMS plans to move forward in 2021 with collapsing the five outpatient payment and documentation levels. (See “Down the Road: The E&M Plan for 2021,” page 39.)


Beginning that year, CMS plans to bring levels 2-4 under one payment rate that falls between the current rate for levels 3 and 4, with the most complex, level 5 visits still being paid at a separate rate. CMS told Texas Medicine the fee schedule includes no policy change for level 1 visits.

That payment structure carries a strong similarity to the one CMS originally proposed for 2019 — which drew a sharp rebuke from TMA in detailed comments on the rule proposal. In the letter (, Dr. Flores and Jeffrey Kahn, MD, chair of TMA’s Council on Health Care Quality, called the proposal “a significant devaluation of the physician’s work.”

The probable 2021 structure includes add-on codes for level 2-4 visits meant to compensate for “inherent visit complexity” for primary care and certain non-procedural specialty care. Those codes would add $13 for both new and established patients. Specialties for which the add-on code would apply include endocrinology, rheumatology, neurology, and obstetrics-gynecology, among others.

The rule also contains add-on codes for “extended” visits — between 34 and 69 minutes for established patients, and between 38 and 89 minutes for new patients. Those codes would each carry a $67 add-on payment.

But physicians have their misgivings about what still looks like an overall payment cut. 

Austin allergy-immunology specialist Alexander Alvarez, MD, who submitted comments of his own last year objecting to the proposed payment structure, says primary care physicians will be hit the hardest.

“I feel like a lot of the primary care physicians are already sort of bearing the brunt of taking care of these Medicare patients and the chronic conditions,” he told Texas Medicine. 

He believes the sickest patients — the ones who today meet the criteria for a level 4 or 5 visit — will “get punted to a midlevel provider,” such as a nurse practitioner or physician assistant. Alternatively — like Dr. Ciammaichella — Dr. Alvarez fears those patients will “have to come in more often to address their medical issues. Because you’re not going to be able to address all of the complicated things that you have to address as part of their care in one visit that’s going to pay you the equivalent of a little bit more than a level 3 visit.”

He hopes that medical societies and physicians will use the delay until 2021 to “come to the table [and] make an argument that maybe these changes shouldn’t go into effect, or they should be modified in some way.”

That’s especially important because, as Dr. Flores notes, the effects of a CMS payment reduction go beyond Medicare: “We always worry about commercial insurers following the lead of Medicare and changing their rules and their payment methods to reflect what Medicare’s doing.” That includes commercially managed Medicare Advantage plans, which must follow Medicare policy.

Physician underpayment, Dr. Flores says, is still the most crucial problem. His practice isn’t taking new Medicare patients, he said, “because we just can’t afford to.” Four years after the repeal of the much-maligned Sustainable Growth Rate (SGR) formula, Dr. Flores says CMS still hasn’t addressed that largest of problems.

“They’re not recognizing the fact that it costs a lot of money to run a practice, and they’re not paying us what it costs to do that,” he said. “SGR went away, but we’re still not getting paid what it takes to take care of patients.” 

Changes to the QPP



Tex Med. 2019;115(1):36-39
January 2019 Texas Medicine Contents
Texas Medicine Main Page 

Last Updated On

June 23, 2020

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Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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