Closed Case? ACR Fights CMS Proposed Changes for E/M Reimbursement

When the Centers for Medicare and Medicaid Services (CMS) proposed coding and documentation changes to consolidate evaluation and management (E/M) services last fall, the ACR was among many specialist societies actively involved in advocating against the proposed ruling. The changes to E/M coding were part of a larger initiative to reduce the documentation burden on providers. But the proposal would also have restructured E/M coding so reimbursement for the care of more complex patients would be reduced.

“The entire physician community reacted to the proposal to collapse the E/M codes, and that was successful in at least delaying that decision,” notes Colin C. Edgerton, MD, a rheumatologist with Articularis Healthcare, Mt. Pleasant, S.C., and chair of the ACR’s Committee on Rheumatologic Care (CORC). As of September 2018, when the comment period closed, more than 15,000 responses had been filed, coming not only from physicians and physician groups, but also from patient groups and bipartisan lawmakers.

For now, the CMS has called a recess for two years before implementation and has asked for justification for changes to the valuation system. Delaying the decision, says Dr. Edgerton, gives the medical community the opportunity to present the administration with additional data, which will bolster the rationale for codes that capture the “complexity density” of E/M visits.

Baseline Inequities
Timothy J. Laing, MD, a rheumatologist at the University of Michigan and a past chair of the ACR’s Government Affairs Committee, was intimately involved in the ACR’s advocacy efforts to forestall the CMS ruling. He says the CMS has indicated a willingness to revisit the rationale underpinning the physician fee schedule.

Rheumatologists and other specialists would like to see reimbursement based on broader parameters than actual time spent with the patient. Indeed, argues Dr. Laing, citing a 1988 study by Hsaio, et al., it should be possible to factor specialty training and expertise into the CPT codes.¹

Rheumatologists have seen reimbursement dwindle with CMS changes over the years. “The consult codes were the last vestige in the fee schedule that truly recognized the value of expertise,” notes Dr. Laing. All of the so-called cognitive specialties—those that are not procedure based (e.g., orthopedics)—should be compensated commensurate with their expertise, he says.

This undervaluing of expertise in the cognitive specialties has far-reaching consequences, Dr. Laing points out. “The gap between the proceduralists and the cognitive specialists has widened. Medical students are guided in their career paths by a number of variables, and income is one of them.”