ARN Physician Featured: 15% E/M Services Reimbursement Hike a Win for Rheumatology

Originally published in The Rheumatologist

The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule final rule for 2020 includes a big win for rheumatologists—a 15% increase in reimbursement for evaluation and management (E/M) services. This decision represents an historic hike in payment for these codes and resulted from 10 years of advocacy work by the ACR and other cognitive care specialists.

The change is set to take effect in January 2021 and is based on revised E/M code definitions developed by the American Medical Association (AMA) CPT Editorial Panel and RUC-recommended values for these services. It will replace the single payment rate policy for level 2–5 services that had previously been proposed by the CMS. The final Physician Fee Schedule also includes a new complexity code that can be added under certain conditions to reflect rheumatologists’ evaluations in cognitive care.

“We are thrilled that this final rule by CMS resulted in significant potential increases in reimbursement to rheumatology providers for their work,” notes Blair Solow, MD, chair of the ACR’s Government Affairs Committee (GAC). “This increase in reimbursement will enable us to recruit young residents into the field of pediatric and adult rheumatology, which in turn will lead to better access to rheumatology providers for patients.”

Reducing Administrative Burden
The immediate impact of this reimbursement increase on the practicing rheumatologist is to alleviate the pressure felt in caring for complex patients, according to Colin Edgerton, MD, FACP, RhMSUS, chair of the ACR’s Committee on Rheumatologic Care (CORC). “Proper valuation of E/M allows rheumatologists to spend the time needed with these patients, and to hire the professional staff needed to coordinate the complex needs these patients have. Similarly, the reduction in administrative burden through measures such as documentation simplification allows rheumatologists and rheumatology professionals to focus on patient care rather than on paperwork.”

Physicians are often required to spend significant time documenting in electronic medical records (EMRs)—often far longer than the face-to-face patient encounters, Dr. Edgerton adds, noting that “much of the documentation is clinically meaningless and is required only for coding and billing purposes—rheumatologists are eager to return documentation to a clinically meaningful exercise.”

Recognizing the Cognitive Specialties
The E/M reimbursement increase also sends an important message that cognitive specialties, such as rheumatology, are valued, which can make rheumatology practice more attractive to medical students and residents at a time when the field faces critical workforce shortages.

Timothy Laing, MD, the ACR’s liaison to the AMA’s RUC and CPT advisory committee, says this E/M increase is far and away the most significant he has seen during his many years of advocacy for payment reform. He notes that credit for this win is shared by many, including the GAC, CORC and ACR’s board of directors and executive committee members. He also points to the Cognitive Care Alliance as an important partner in lobbying and advocacy activities on this topic.

The Cognitive Care Alliance, an ad hoc organization led by John Goodson, MD, coordinates several cognitive medical societies to boost the effectiveness of communications with members of Congress and various officials in the CMS. It has worked to convey the negative impact over time as evaluation and management services become increasingly undervalued, “so much so that serious physician workforce shortages and patient access issues were becoming increasingly apparent,” Dr. Laing shares. “Happily, that message was received, and CMS agreed with the increases that were ultimately recommended by the AMA Relative Value Committee. As we await the next final rule from CMS, each of these advocates will continue supporting final rule implementation.”

Ongoing Advocacy for Complex Care Reimbursement
Advocacy for better valuing the expertise and complex care provided by rheumatologists dates back to 1992 after the CMS adopted the Resource-Based Relative Value System, according to Adam Cooper, MS, senior director of ACR government affairs. In 2010, after the Affordable Care Act became law and included implementation of a primary care bonus, rheumatologists and other cognitive specialists were excluded from receiving the bonus solely because of specialty designation. However, rheumatologists bill the same E/M codes as primary care doctors, primarily provide office visit services and often serve as a principal care provider for their patients.

“The bonus later expired, but the ACR’s advocacy for better recognizing and reimbursing the complex care provided by rheumatologists continued and helped result in the E/M improvements and increases in the 2020 fee schedule final rule,” Mr. Cooper says.

Changes identified in the 2020 Physician Fee Schedule and Quality Payment Program final rule that affect rheumatology include the following:

  • A 15% increase for E/M reimbursement for rheumatologists;
  • A single complexity add-on code (GPCX1) available to all specialties for visits that are part of ongoing care related to a patient’s single, serious or complex chronic condition;
  • Reduced reimbursement for physical therapists, which the ACR opposes on the grounds that the role of occupational and physical therapists should be appropriately valued to protect patient access to these services;
  • New care management codes that separate coding and payment for Principal Care Management (PCM) services;
  • A policy that allows a physician, resident or nurse to document that the teaching physician was present at the time the service was delivered; and
  • An additional Merit-Based Incentive Payment System (MIPS) pathway.

The ACR responded to the final rule to share input, suggestions and concerns regarding implementation of these changes. The 2020 rule does have one important caveat: Changes incorporated in the final rule could still be modified due to provisions in the rule that require changes not to take effect until 2021.

Prior to implementation of the 2020 final rule, the ACR advocacy team, including volunteers and ACR staff, is joining forces with other cognitive specialties in Hill meetings to remind legislators of the importance of these updates to cognitive care. They are also emphasizing how much data and other information have been considered by the CMS in making this decision, according to Lennie Shewmaker, JD, ACR’s director of congressional affairs. “We remain in contact with CMS to support their rule as it was presented and urge them to implement that language as finalized in January 2021.”

Keep the Conversation Going
The ACR is also working with other cognitive care specialties to thank the CMS and members of Congress for their support of the rheumatology specialty and to offer support during implementation of the final rule, notes Amanda Grimm Wiegrefe, MScHSRA, ACR’s director of regulatory affairs. “We continue to advocate for implementation to occur on Jan. 1, 2021, as written,” she says, noting the ACR does not anticipate the fundamental E/M valuation increase to change in the next CMS Physician Fee Schedule proposed rule that is due out in July.

Ms. Grimm Wiegrefe and other ACR staff are monitoring whether the complex care code (GPC1X) may be delayed to allow sub-regulatory guidance and to alleviate the dramatic reimbursement changes for other specialties.

In the meantime, the ACR continues to work with cognitive care colleagues to ensure the value of these specialties is appropriately recognized by payers, particularly the CMS. In this work, Ms. Shewmaker stresses the important role members can play by reaching out to their legislators to thank them for supporting these updates and urging them to support the CMS in implementing them on time.

Send your thanks and support for these changes to members of Congress and follow developments on implementation of the E/M pay increase by visiting the ACR’s Legislative Action Center.

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