On Dec. 8, 2017, members of the Cognitive Care Alliance (CCA)—of which the ACR is a leading member—met with members of Congress on the Hill and representatives from the Centers for Medicare and Medicaid Services (CMS) to discuss ongoing concerns about the inadequacy of existing evaluation and management (E/M) codes to properly remunerate cognitive services provided by rheumatologists.
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The meeting followed on the heels of a final rule issued by the CMS on Nov. 2, 2017, on policy, payment and quality provisions in the Medicare Physician Fee Schedule for 2018.1 In the final rule, no substantial changes were made to existing E/M codes for cognitive services, but the CMS did acknowledge that current guidelines on E/M codes may be outdated and in need of revision. The CMS invited stakeholders to collaborate with it on implementing needed changes for future rulemaking.
In the December meeting, the ACR and other members of the CCA urged the CMS to conduct a study of cognitive E/M work to restore accuracy and precision to the Physician Fee Schedule. The results of the study would be used to develop new service codes, more appropriately value cognitive work and develop new documentation requirements to reduce administrative burdens and better utilize existing electronic health record (EHR) technology.
According to Tim Laing, MD, former chair of the ACR Government Affairs Committee and the ACR’s physician representative to the CCA, who attended the meeting, the special advisors to the CMS Administrator agreed to study the information that the CCA provided on the need for revamping of the E/M codes for cognitive services.
“We believe current payment methodologies cannot capture the intensity and complexity of cognitive care services, and we impressed on them [the CMS advisors] our strong recommendation that CMS commission a comprehensive study of these services,” says Dr. Laing.
The overall changes to the E/M codes for cognitive services that the ACR would like the CMS to make were detailed in an August 2017 response the ACR sent to the Committee on Ways and Means and Subcommittee on Health Regarding Statutory and Regulatory Burdens on Optimized Efficiency and Patient Care. In the submission to the subcommittee, the ACR highlighted the failure of the existing E/M codes to adequately describe the work demanded by cognitive medical practice, and also emphasized that the codes have not maintained their relative valuation regarding other physician services with Medicare’s Physician Fee Schedule.
The CCA reiterated these concerns in the December meeting and laid out a number of specific concerns regarding the insufficiency of the existing E/M codes. Underlying all of these concerns is the recognition that the content of clinical care has changed substantially over the past two decades and the failure of the existing E/M codes to capture the increasingly complexity of cognitive services. This has led to a cascade of challenges and difficulties for rheumatology practices. Because of the insufficiency of existing codes to accurately describe the complexity of cognitive services, these services are underpriced. This, in turn, is leading to a shortage of physicians required to deliver comprehensive healthcare services to help patients manage chronic illness.
In addition, the existing E/M codes reflect an increasingly outdated mode of delivering healthcare. Instead of the emerging model of collaborative care in which a multidisciplinary group of physicians and non-physician health professionals deliver healthcare, current E/M codes still reflect an older model of healthcare delivery through siloed providers working on their own.
Adam Cooper, MS, the ACR’s senior director of government affairs, noted as well that the current Physician Fee Schedule tends to favor procedures over the face-to-face E/M visits that make up the majority of the reimbursed care provided by cognitive specialists, such as rheumatologists.
Mr. Cooper underscored the ongoing advocacy the ACR is doing to ensure the services provided by rheumatologists are better and more appropriately valued in the payment system. He emphasized that payment for evaluation and management should be improved for both primary care and cognitive care providers. “Our members bill the same E/M codes as primary care providers, face similar workforce shortages as primary care, and much of their expertise and work done in care coordination is still not currently recognized in payment,” he says.
Members of the CCA plan to meet again with the CMS in the near future to discuss these ongoing issues, and to continue to urge the CMS to pursue a study to ensure sufficient enumeration of cognitive services. The ACR is also a member and leader of the Cognitive Specialty Coalition, a related group that has been working to promote better recognition for cognitive specialties for several years, and which includes the specialties of rheumatology, neurology, endocrinology, infectious diseases, psychiatry, neuro-ophthalmology and allergy/immunology as its members.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.
- Centers for Medicare & Medicaid Services (CMS). Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year 2018. 2017 Nov 2. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html