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A Good Outlook for Payments of E/M Visits

In the fall of 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2019 Medicare Physician Fee Schedule (MPFS) rule addressing Medicare payment rates and policy provisions for physicians in 2019. While the rule included welcomed proposed reductions in medical history and exam documentation requirements, the portion that suggested the collapsing of levels 1-5 payments on the MPFS for evaluation and management (E/M) visits into single payments by blending levels 2-4 into one payment rate starting in 2021 received immediate pushback and criticism from the physician community, forcing CMS to delay its implementation.

On July 29, 2019, the CMS released yet another set of rules for calendar year (CY) 2020, but there are no significant updates for E/M coding, payment, or documentation requirements for CY 2020, as it was established in the 2019 rule that changes would not issue until CY 2021.

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In the latest released set of a 1,200+ page rule on July 29, CMS included proposed changes, as suggested by the American Medical Association (AMA), to payments for E/M visits starting in CY 2021. Below is a basic summary.

Proposed payment changes for E/M visits in CY 2021:

1.  Maintain a separate payment rate for all E/M levels, although it is being proposed to delete CPT code 99201 (Level 1 new patient office/outpatient E/M visits).

2.  In addition to the base E/M visit levels, create two ADD-ON codes/descriptors that could be reported with an E/M visit:

a. Code 99XXX to describe a prolonged office/outpatient visit when time is used for code level selection and the time for a Level 5 office/outpatient visit is exceeded by 15 minutes or more on the date of service.

b. Code GPC1X would describe the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.

While things will remain the same in CY 2020, it should be noted that the changes proposed for CY 2021 in this area are the result of the healthcare community making its concerns known and then working with the agency to find better solutions. As a result, the proposed rules overall appear to provide the increased flexibility for a physician to best and more accurately reflect his or her care of a patient, meet patients’ needs with less burden, and receive proper compensation.

The January 1, 2021 implementation will allow time for provider education, updates to EHRs, and changes to workflow.   


Gabriela Villanueva is CAP’s Public Affairs Analyst. Questions or comments related to this article should be directed to