September 6, 2018
The Honorable Seema Verma
Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room 445–G
200 Independence Avenue, SW
Washington, DC 20201
Re: Medicare Physician Fee Schedule for CY 2019 (CMS-1693-P)
Dear Administrator Verma:
The American College of Occupational and Environmental Medicine (ACOEM) appreciates the opportunity to provide recommendations to the Centers for Medicare & Medicaid Services’ (CMS) proposed changes to the Medicare Physician Fee Schedule for 2019.
ACOEM agrees with the CMS proposed plan to eliminate the detail-oriented bullet system requiring specific elements of history and examination in an evaluation and management (E/M) encounter. We also support the proposal to permit coding levels of care to be determined by documentation of medical decision making (MDM), but recommend that CMS modify the MDM criteria to support a movement from the disease/cure model to one that promotes optimal function. MDM coding rules should align with risk identification and mitigation, taking into consideration risk for harm related to medical excess (e.g., unnecessary medication or surgery). MDM coding rules should also focus on planning medical treatment that will improve health care outcomes for patients and promote optimal functional status.
While we support the changes to the E/M encounters and the MDM as noted above, ACOEM disagrees with the following sections of the CMS proposal:
1. Permit time spent with the patient as the sole criterion for level of care. This would disincentivize efficiency and could easily be manipulated by more opportunistic providers. There is nothing about this element of the CMS proposal that addresses quality of care. Furthermore, it would not be expected to improve patient outcomes.
2. Lump care levels 2-5 with a single payment level. We feel that this would lead to norming toward a lower standard of care, which would lead to worse patient outcomes. It would also lead to “churning” with providers scheduling multiple visits with a patient to address multiple problems. This would increase costs and decrease convenience to patients. In geographic areas that have primary care access problems, doctor appointments are likely to become even less available.
3. Eliminate the use of “mod-25” and reduce the payment for additional services performed on the same day as an office visit. It will often be much more convenient for patients to receive certain office procedures, such as a joint injection or skin biopsy, during routine office visits scheduled for other diagnostic reasons, rather than requiring them to return for a separate visit, which would be a likely outcome of this proposal. Furthermore, such a change may cause many family physicians and other primary care providers to discontinue performing office procedures, particularly in rural areas where they may be the only local provider.
ACOEM urges CMS to consider how its proposed changes are likely to impact quality of care or help America’s clinical providers deliver better health outcomes for a population that continues to present with complicated medical issues, including chronic pain and addiction. CMS has an opportunity to make some meaningful changes with its E/M revisions, changes that should include risk assessment and risk mitigation related to functional outcomes, opioid use and harmful or excessive medical care. ACOEM has unique expertise in evaluating and promoting the ability of adults to remain in the workforce. We urge CMS to take advantage of our expertise in defining and promoting outcomes that align with optimal participation in work and society, which will ultimately decrease the need for Social Security Disability and premature utilization of Medicare benefits.
ACOEM endorses the American Medical Association’s proposal to establish a workgroup of physicians and other health professionals with deep expertise in defining and valuing codes, and task this workgroup to analyze the E/M coding and payment issues to arrive at concrete solutions that can be provided to CMS in time for implementation in the 2020 Medicare Physician Fee Schedule. Although ACOEM members do not usually treat Medicare patients, ACOEM has been deeply engaged in the analysis of E/M coding rules for several years, as evidenced by the 2016 guidance statement “Defining Documentation Requirements for Coding Quality Care in Workers’ Compensation.”1 If this workgroup is established, ACOEM wishes to be a member.
William Buchta, MD, MS, MPH, FACOEM
1Cloeren M, Adamo P, Blink R, et al. Defining documentation requirements for coding quality care in workers' compensation. J Occup Environ Med. 2016;58(12):1270-5.