Insurers Preempting Upcoming Changes for E/M Visit Documentation

On November 15, 2019, the Centers for Medicare and Medicaid (“CMS”) published the 2020 Physician Fee Schedule Final Rule in the Federal Register. Among the several changes outlined in the rule, this post specifically focuses on the changes to documentation requirements for Evaluation and Management (“E/M”) Visits. The first important note is the CMS will maintain the existing documentation requirements for all E/M codes for the year 2020.

However, in an effort to update the currently applicable guidelines (published in 1995 and 1997), the E/M documentation requirements will be revamped in 2021 for office visits only. In other words, the emergency department E/M code documentation will remain unchanged. But the focus of the E/M code documentation for office visits will be based solely on Medical Decision-Making (“MDM”) or E/M visit time with patient.

Currently, the E/M Current Procedural Terminology (“CPT”) codes have three elements within their code descriptors: the history of present illness, the physical examination, and MDM. And under the applicable CMS guidance, only two of the three elements are needed to support the CPT code used for an office E/M visit. Eventually, CMS will move away from the documentation on the history and exam when it comes to E/M visits in the office setting, but based on the final rule, that will not be until 2021 and after all industry stakeholders have any opportunity to weigh in on the final MDM documentation requirements.

However, some insurers have improperly decided to adopt this policy early with claims that have dates of service beginning in 2019 without any published guidelines outlining how the insurers will evaluate the MDM documentation when assessing whether the medical record adequately supports the level of service billed. Not surprisingly, this has led to the inappropriate wholesale denials or down coding of claims by insurers without adequate explanation. Moreover, the insurers have extended this policy to include emergency department E/M services that were expressly not included in CMS proposal.

In the event your organization is experiencing denials or down coding on this basis, please contact Greg Brodek, Sean Zabaneh, Brad Thompson, Erin Duffy, or any of the other provider reimbursement attorneys at Duane Morris LLP.