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Stephanie Pellitt

, National Council for Behavioral Health

National Council Submits Comments on Medicare Physician Fee Schedule Rule

September 13, 2018 | Medicare | Workforce | Comments
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This week the National Council for Mental Wellbeing submitted comments to the Centers for Medicare and Medicaid Services (CMS) on its proposed rules for the 2019 Medicare Physician Fee Schedule (MPFS). The proposed rules update payment rates and key policies applicable to physicians and other professionals under Medicare. Among the key changes supported by the National Council were initiatives to reduce billing documentation requirements for Evaluation and Management (E/M) services, base reimbursement for office visits on the level of medical decision-making required, allow for same-day visits and create a bundled payment for the care and management of substance use disorders (SUD) in Medicare.


Office Visit Documentation, Coding and Billing: CMS’s proposed rule would change documentation and reimbursement for E/M office visits in two major ways.

First, under reporting and documentation, instead of requiring practitioners to use the existing 1-5 levels standards for deciding the level of E/M code for outpatient, office-based medical reporting and documentation, CMS proposes allowing practitioners to:

  • Select the E/M visit’s level (1-5) based on either time spent face-to-face with the billing practitioner or the complexity of medical decision-making, instead of also accounting for the extent of history taken and examination during the visit. Practitioners could choose to continue using existing selection standards.
  • Change the floor for documentation standards, such that documentation would only need to match that of a Level 2 service. As with the changes to level selection, practitioners could choose to continue using existing documentation standards.

Second, regarding reimbursement for office-based E/M visits, CMS proposes collapsing the reimbursement into two tiers: one for Level 1 E/M visits, and one for Levels 2-5.

In official comments, the National Council applauded the proposal to determine the billing code level based solely on Medical Decision Making (MDM). Under current Medicare rules, visits with very complex patients with multiple mental illnesses, substance use disorders (SUD), intellectual disabilities and even legal or social complexity are coded as having a low-level of complexity as they do not involve a physical exam and/or more than one organ system. At the same time, the National Council expressed concern about the companion proposal to consolidate reimbursement rates such that there is only one rate for levels 2 through 5. Since the proposal would set that rate below the reimbursement rate of a Level 4 office-based service, the National Council fears that this will result in substandard care for people with complex health conditions such as serious mental illness or addiction disorders. As a result, the National Council recommended that CMS not implement for 2019 the changes to reimbursement rates and, instead, retain separate reimbursement rates for all five E/M levels.

In the interim, the National Council expressed support for CMS to move forward with the following provisions of the 2019 proposed rule pertaining to E/M visits:

  • Use of Medical Decision Making for E/M Level Selection: allowing for E/M level selection based on the complexity of Medical Decision Making
  • In-Home Visits:Removing the need to justify providing a home visit instead of an office visit.
  • Interval History: Changing the required documentation of the patient’s history to focus only on the new information since the previous visit;
  • Re-Documentation Requirement: Eliminating the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or by the patient; and
  • Same-Day Services: Eliminating a policy that prevents payment for same-day visits with multiple practitioners in the same specialty within a group practice. This will save patients time and money by giving them an opportunity to schedule their medical appointments more efficiently.


In an effort to address the opioid crisis, CMS requested feedback on the potential creation of a new Medicare bundled payment for the care and management of substance use disorders. The National Council expressed strong support for this proposal, while raising larger issues of access to SUD treatment for Medicare beneficiaries. The National Council recommended creating two separate bundled payment options for SUD treatment – with one bundle including medication-assisted treatment (MAT) and a separate bundle for SUD treatment that does not have a MAT component. Further recommendations included designing the SUD bundled payment option(s) in a way that allows for all forms of medication-assisted treatment (methadone, buprenorphine, and naltrexone), recognizes and responds to the chronic disease nature of SUDs and allows non-Medicare billable treatment providers (such as Opioid Treatment Programs, professional counselors and marriage and family therapists) to supply services to be included in the bundled payment.

For more details, please see the National Council’s full CY 2019 Medicare Physician Fee Schedule comments here.