In July of this year, CMS released groundbreaking proposed rule changes that, if implemented, will dramatically change the way physicians document and get paid for their work. In broad terms, CMS is seeking to reduce the administrative burden on physicians by allowing the documentation of face-to-face time spent with the patient and or the medical decision making portion of the service only to support the billing of an Evaluation and Management (E/M) service and, for teaching facilities, allowing residents and even nurses to document the extent of the teaching physician’s presence and participation in the resident’s service instead of requiring the teaching physician to document this themselves. This is on the heels of an earlier CMS decision, published in February of this year, which allowed teaching physicians to bill using a medical student’s E/M visit note by signing and dating the student’s note rather than re-documenting the key elements of the service as formerly required.
It is hard to describe the magnitude of these proposed changes other than to say that they have flipped the healthcare world in this area on its head. For almost 25 years, it has been a bedrock principle of medical record auditing that payment of a service was determined by the amount of documented work performed, and that, with a few exceptions, only services documented by the performer of a service supported the billing of a service. As years of increasing amounts of money recouped by the Department of Justice for cases of fraud and abuse since 1995 (with the initiation of Medicare Physicians at Teaching Hospitals, or PATH, audits) demonstrate, these principles have existed with good reason. Even well-intentioned and ethical physicians get extremely busy and look for efficiencies. Sometimes, shortcuts are adopted in the process and the descent down this very slippery slope can and have led some into medical billing fraud and even compromised medical care.
In proposing a blended rate for E/M payments, CMS has appeared to hit on a solution to over coding. Over coding can’t really exist if there is essentially only one level of payment. They have also appeared to address the inequities inherent in the new payment method by the addition of add-on codes for primary and specialty care. But allowing physicians to support their billing by a simple statement of how much time they spent with the patient or by having someone else document their level of participation in a service appears to be opening, not closing the door on fraud. Even while proposing their changes, CMS appears to be expressing concern about this by stating their intention to “monitor the results of this proposed policy for any program integrity issues.” (Federal Register, page 35837.) But how, once the linchpins of medical record auditing mentioned above are removed, do they intent to do that? How will they be able to monitor the results once the documentation requirements that were designed to prove performance of a service are reduced to next to nothing? After years of listening to complaints from the physician world about the inadequacies of the present documentation requirements for physician visits without changes, CMS should be commended in their efforts at delivering a practical response. Nevertheless, these are very significant questions that should be addressed well before any changes are initiated.
About the Author: Brian Meredith, CPC, is president and founder of Healthforce, Inc., a healthcare administrative consulting firm with a focus on revenue integrity through compliance, coding and billing guidance. He has more than 20 years’ experience in the healthcare industry, which formerly includes director of billing compliance at Boston Children’s Hospital, compliance and coding consultant with Public Consulting Group in Boston, Mass., and compliance specialist with UMass Memorial Medical Group in Worcester, Mass.
