Don't have a TCI SuperCoder account yet? Become a Member >>

Outpatient Facility Coding Alert

CMS News:

AAFP Asks CMS for More Codes for Outpatient Settings

A proposal calls for inclusion of new codes in the 2018 Medicare physician fee schedule. 

Physician organizations are requesting that CMS redefine and revalue the outpatient E/M codes to reflect the broad range of services physicians provide.

Unlike new physician payment models which are using technology to change the patient care, payment for primary care physicians who provide outpatient evaluation and management (E/M) services has remain unchanged. 

In the new system, with variables like accountable care organizations and the comprehensive primary care initiative, physicians are interacting with patients and the entire care team in multiple ways. But the catch is that outpatient E/M codes remain the basic building blocks for reporting such care, which means changes in care delivery cannot be completely integrated in the current payment structure.

The American Academy of Family Physicians  (AAFP) recently signed a letter with other physician organizations asking CMS to redefine the outpatient E/M codes to reflect the broad range of services that physicians provide and to increase the payment for such services. The letter explains that CPT® codes 99201-99205 and 99211-99215 no longer are sufficient to represent the variety of care being provided to Medicare patients.

“A by product of this transformation in care is that the CPT® codes for outpatient E/M services no longer describe the work performed by physicians and their clinical staff,” the letter reads.

It is surprising that the E/M codes have not been revised for 25 years, but the nature of patient encounters has. Now the testing and diagnostic procedures are much more complex. Progress in medication management and technological advances now enable physicians to focus more on disease prevention and chronic care management.

“Physicians spend less of their time treating acute illnesses and more of their time, appropriately, trying to ensure optimal outcomes efficiently,” the letter reads.

It is imperative for CMS to know the different types of care the physicians provide in outpatient care settings. At the end, the letter includes a list of 11 goals and principles the AAFP and others hope to realize through research and documentation addressing the need for new codes.

The AAFP and other signatories on the letter ask CMS to hire a contractor who would study in full detail the range of outpatient E/M services provided to patients. A proposed timetable suggests beginning the work this summer with a series of meetings and conference calls that would last until November. The contractor would then collect data through October 2016.

A final list of recommendations would be presented to CMS by February 2017, which would allow enough time for the new codes to be included in the 2018 Medicare Physician Fee Schedule, if CMS agrees.

“We believe that new codes must be developed from a knowledge base that reflects the current levels of outpatient E/M physician work based on nationally representative samples and electronically accessible data,” the letter reads.

The proposal specifically calls for only one set of outpatient E/M codes that would be applied to all physicians and other health professionals. Representatives from the AAFP and other specialty societies pledged to participate on advisory groups if requested.

Resource: To read the letter from AAFP and other organizations, download the PDF at