21 Dec 2019 CMS Changes: What Will Change for Your Practice?
I have spoken with many of you about the proposed CMS changes that are scheduled to take place over the next few years. From my perspective, they fall into two categories: what’s happening 1/1/19 and what is anticipated to change in 2021. Regardless of what kind of practice you are in, or what your role is, everyone should take the time to explore the implications of these changes on your pediatric practice.
Effective 1/1/9 CMS is instituting two significant changes: decreased clinician documentation burden and elimination of the ambulatory facility fee for services furnished by certain-off campus hospital outpatient provider-based departments. It is important to note that this is for Medicare patients. However, history tells us that private payers and Medicaid often adopt Medicare rules, but the pace of their implementation can be highly variable.
Regarding documentation burdens: the changes state that for established patient office/outpatient visits, “when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.”
Office Practicum is busy planning the most effective way to make appropriate updates in order to support this streamlined documentation. However, it is important to note that documentation information in the EHR serves other purposes in addition to satisfying coding requirements. Documentation must be appropriate for medical-legal reasons, to communicate to colleagues/healthcare team members inside and outside the office, and to share information with patients. In addition, while CMS can make this date effective 1/1/2019, we cannot be sure that all payers will follow these changes, and if so, when. The American Academy of Pediatrics has reached out to major payers to ask this question and to inquire about their formal instructions to third party auditors they utilize.
Additionally, CMS has clarified that for E/M office/outpatient visits for new and established patients: “practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.”
Office Practicum is excited about the implications of this clarification. This paves the way for innovation where families may be able to document some of the information themselves. At a minimum, this removes the requirement that providers must do this data entry themselves (as evidenced by timestamp or an audit log) and allows for team-based documentation and review where appropriate. However, it is important to remember that it is ultimately the responsibility of the provider who did the work to review the summary and make sure that the note accurately reflects the information conveyed and what occurred in the visit. This is true regardless of the use of templates or team members entering data on behalf of the provider.
The most appropriate action for many practices may be to wait for formal responses from your specific payers before instituting changes in documentation practices.
Elimination of the facility fee may have varying degrees of impact on your practice depending on your regional healthcare environment. Some practices have attracted families, especially those with significant patient payment responsibility (such as high deductible health plans), precisely because their fees are lower without the health system facility fee. Other practices feel this will “level the playing field” so the larger systems will not automatically get paid better to perform the same work. Some regional healthcare systems/networks may determine that without the facility fee they can no longer afford to employee outpatient pediatricians. If this is the case, there may be unemployed pediatricians in your area looking for a new place to practice. Are you planning a way to attract and engage them?
Regarding the “flattening” of payment for E/M services 99212-99214 and the ability to determine what documentation schema to chooses for the visit: stay tuned. CMS is planning to implement them in 2021 but there are several powerful medical organizations who are fighting these changes. In the meantime, you can explore the potential impact to your organization by using the calculators provided by Paul Vanchiere from the Pediatric Management Institute.
Change is upon us. Take the time to pause from the daily grind of taking care of the patients in front of you, and look up long enough to consider the implications on the future of your practice.