key: cord-0013217-8yo2v440
authors: Fleishon, Howard B.
title: Evaluation and Management Coding Initiative
date: 2020-10-12
journal: J Am Coll Radiol
DOI: 10.1016/j.jacr.2020.09.057
sha: 77c7f437c69a61c724e7f03909adb98ed37b3c66
doc_id: 13217
cord_uid: 8yo2v440

nan

Over the course of several years, the ACR's Government Relations and Economics Commissions and staff have focused on the evolution of the Evaluation and Management (E&M) coding restructure and revaluation, knowing that significant changes to this code set could directly impact Medicare providers who do not bill these services. Starting January 2021, the administration will put into place a dramatic reallocation of funds in the Medicare Physician Fee Schedule (MPFS). These changes could have a significant, negative impact on over a million Medicare providers, including radiology and radiation oncology practices.

Strong centers of influence for decades including multiple administrations, policy think tanks, different Congresses, and primary care specialties have advocated for greater reimbursement for primary care providers since the creation of the resource-based relative value scale payment system. The most recent efforts to redistribute monies in the physician fee schedule have manifested in several pathways. First, existing Current Procedural Terminology codes describing office and outpatient E&M services typically used by primary care providers were revised through the AMA's Current Procedural Terminology Editorial Panel process and revalued by the AMA's Relative Value Scale Update Committee. CMS subsequently approved the specific increases in the work values [1] . These E&M-based codes are the highest-volume codes used in the MPFS but are rarely used in radiology. The second is that there are two new add-on codes to be billed with complex and extended visits.

As we discuss physician payment policies in the Medicare program, it is important to remember a fundamental underpinning of this payment system: Unless Congress intervenes, changes to codes that result in payment increases or decreases have to be absorbed within the payment system [2]. In other words, it is a zero-sum game that is budget neutral to the federal budget. Under these budget neutrality rules, whenever increases are realized in one family of codes, the cost needs to be recovered from elsewhere. In the 2021 MPFS proposed rule, the conversion factor that applies to all codes was adjusted downward such that the net result of all costs for physician services is neutral [3] . Bottom line, along with other adjustments, radiologists are scheduled to lose 11% reimbursement on an average annualized basis for Medicare services, and some specialties who are heavy billers of E&M services will see increases in their reimbursement up to 17%.

If implemented, these changes would be overwhelming. The impact to our practices, departments, and profession cannot be overstated. Providing safe, high-quality services for our patients is dependent upon financial viability. Most of our revenue is realized through clinical work. Even academic institutions are dependent on clinical revenues to support their triple aim of clinical work, research, and education. This revaluation promises to impact services under the MPFS. In addition, many commercial insurance contracts are either tied to the MPFS or renegotiations will be influenced by the decisions of the largest payer of medical care in the country. Also, Medicare has already suggested that changes to E&M services in other settings are being considered.

My apologies if this is repetitive information. My purpose is to provide context for the massive ACR Association (ACRA) advocacy effort that has been under way. We are investing every resource, influence, and idea to address the E&M issue. On a regulatory level, CMS is saying that they are committed to this pathway to increase pay for primary care. Any impacts, such as radiology cuts from budget neutrality, are a consequence of budget neutrality determinations made by the legislative branch of government and therefore not under the control of CMS. ACRA has amassed a coalition of 53 organizations of physician specialties like surgeons and their subspecialties, as well as nonphysician providers such as physical therapists and social workers. They have joined our coalition to lobby Congress to address these cuts by either suspending budget neutrality or preventing implementation of the revaluations until further study. This large coalition is also linking arms to fight CMS directly and assert as much pressure as possible to force the agency to put into place policies that will mitigate the significant cuts looming over so many providers or delay implementation until the consequences of this reimbursement shift in this period of coronavirus disease 2019 can be assessed.

ACRA is deservedly recognized by Congressional representatives, other medical organizations, and our members as one of the most accomplished and credible medical advocacy groups in Washington, but that does not translate into achieving every goal or successfully defending each challenge. In this case, addressing the E&M code revaluation in the proposed rule is an uphill battle. There is tremendous momentum and investment in Washington to help primary care. There is no appetite to increase federal spending on physician services beyond what has been offered in previously passed coronavirus disease 2019 relief packages.

We are facing this impending implementation together, as a community within radiology and as a coalition of a wide variety of providers who provide invaluable, necessary services to Medicare beneficiaries. However, in this unprecedented upside-down year of a worldwide pandemic, coupled with the most incredibly partisan and divisive election period in Washington, it is impossible to predict how this fight will play out. Be assured that we will continue to explore every avenue to protect our profession. We will always continue to fight for fair and just payment for our services and our profession. Now more than ever, our long-term commitment to representation through the ACR is vital to maintain medical imaging access for our patients .  107  108  109  110  111  112  113  114  115  116  117  118  119  120  121  122  123  124  125  126  127  128  129  130  131  132  133  134  135  136  137  138  139  140  141  142  143  144  145  146  147  148  149  150  151  152  153  154  155  156  157  158   159  160  161  162  163  164  165  166  167  168  169  170  171  172  173  174  175  176  177  178  179  180  181  182  183  184  185  186  187  188  189  190  191  192  193  194  195  196  197  198  199  200  201  202  203  204  205  206  207  208  209  210 

AMA update codes for office visits