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CMS Proposes Changes to E&M Codes for January 2019

August 13, 2018

CMS Proposes Changes to E&M Codes for January 2019

The 2019 Medicare Fee Schedule Proposed Rule was published July 12, 2018. One of the most talked about recommendations is the proposed changes to the current Evaluation and Management (E&M) codes. CMS is proposing a number of coding and payment changes in an attempt to "reduce administrative burden so that the practitioner can focus on the patient ...and improve payment accuracy for E&M visits."

The Proposal

The proposed changes would only apply to office/outpatient visit codes (CPT codes 99201 through 99215).

The overarching proposal is to collapse the payment and documentation requirements for levels 2-5 for both new and established patients. The Level 1 (established patient) codes, which normally does not require the presence of a physician, will remain at a separate rate; the other levels (2-5) are proposed to be paid at a single blended rate.

The table below from the Federal Register further illustrates the code change and associated reimbursement proposal.

CMS would Require practitioners to bill the CPT code for whichever level of E&M service they furnished but they would be paid at the single rate. It will not be material to Medicare’s payment decision which CPT code (of levels 2 through 5) is reported on the claim, except to justify billing a level 2 or higher visit in comparison to a level 1 visit.

 Some other notable proposals included in the Rule are to:

  • Apply a minimum documentation standard so practitioners would only need to meet documentation requirements for a level 2 visit for History, Exam, and/or MDM (except when using time to document the service)
  • Allow practitioners to choose to document office/outpatient E&M visits using one of the three options:
    • Medical decision-making
    • Time
    • Current 1995 or 1997 E&M documentation guidelines
  • Document only what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history
  • Remove the prohibition that multiple providers in the same group can't bill E&M services the same day
  • Use the amount of time personally spent by the billing practitioner face-to-face with the patient to document the E&M visit regardless of the amount of counseling and/or care coordination furnished as part of the face-to-face encounter
  • Create a new multiple procedure reduction policy for visits and procedures reported on the same date (50%)
  • Create a new prolonged service code for any visit lasting more than 30 minutes beyond the office visit (with reimbursement about $67)
  • Create a new add-on payment amount of about $5 for primary care office visits to address visit complexity inherent in primary care services
  • Create a new add-on payment amount of about $12 for office visits performed by certain specialties:
    • Allergy, Immunology
    • Cardiology
    • Endocrinology
    • Hematology/Oncology
    • Interventional Pain Management
    • Neurology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Rheumatology
    • Urology

Next Steps - Comment!

CMS is seeking public comment on these proposals to provide practitioners choice in the basis for documenting E&M visits. They are interested in commenters’ opinions as to whether E&M visit proposals would, in fact, support and further the aforementioned goals. Submit comments by September 10, 2018.

1. Electronically at Follow the “Submit a comment” instructions.

2. By regular mail to the following address only:
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1693-P
P.O. Box 8016
Baltimore, MD 21244-8016

3. By express or overnight mail to the following address only:
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1693-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850

Comments submitted via fax will not be accepted.

Here are some additional resources on the Proposed Rule:

Contact LAMMICO Practice Management Specialist, Natalie B Cohen, MBA, MHA at 504.841.2727 or for more information or consultation.

This is not legal or financial advice, and is not intended to substitute for individualized business or financial judgment. It does not dictate exclusive methods, and is not applicable to all circumstances.


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