Radiology Gets a Smaller Slice of the MPFS Pie

Gregory N Nicola, MD, FACR; Lauren P Golding, MD

Disclosures

Appl Radiol. 2021;50(1):28-30. 

In This Article

Reducing Burden

In October 2017, Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma announced the agency's "Patients over Paperwork" initiative, which arose out of President Donald Trump's executive order to reduce burdensome regulations inside federal agencies.[5,6] The goals were to:

  • Increase the number of satisfied customers—clinicians, institutional providers, health plans, etc—engaged through direct and indirect outreach;

  • Decrease the hours and money clinicians and providers spend on CMS-mandated compliance; and,

  • Increase the proportion of tasks that CMS customers can perform completely digitally.[7]

A common grievance of many clinicians is the amount of time needed to document patient encounters inside electronic health records (EHR).[8] Among the most frequent encounters requiring such documentation are face-to-face visits termed Evaluation and Management services (E&M).[9] The CMS targeted a specific set of E&M services in the first rule-making cycle following "Patients over Paperwork," specifically the outpatient E&M services (office-based visits). Inside the 2019 MPFS proposed rule, CMS went big, drastically changing the entire structure, documentation requirements, and payment to this family.[10]

Prior to this proposed rule, CMS paid for five levels of outpatient visits for new patients, and an additional five levels of visits for established patients. Each level in each category (new vs established patients) had a distinct payment which increased with the "level" of the visit corresponding to the complexity of the patient. The levels of the visit required cumbersome documentation, such as history and physical examinations that increased in complexity as the level escalated.

Inside the 2019 Proposed MPFS rule, CMS restructured and collapsed levels 2–4 into a single payment for new and established patients, and reduced documentation requirements to comply with the executive order. CMS also created an add-on code for prolonged services, as well as a controversial add-on code for payments for specific specialties the agency deemed to require additional resources. These codes are beyond the scope of this article, although they do have potential political and strategic implications.

CMS proposed a blended payment structure for the new outpatient E&M codes, reducing overall payments for the higher complexity codes (Table 1). While the broader house of medicine did not object to the reduction in documentation requirements, CMS created a burning platform for stakeholders by drastically altering payments to this family.

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