Society Asks for Parity on E&M Coding in Comments to CMS

October 3, 2019
Policy Snapshot

For the second year in a row, the Centers for Medicare & Medicaid Services (CMS) proposed sweeping changes to evaluation and management (E&M) coding. In its annual release of the physician fee schedule (PFS) proposed rule, CMS proposed to align the previously finalized E/M office visit coding changes with the framework adopted by the American Medical Association’s CPT Editorial Panel. Since last year’s proposal, which was met with harsh criticism from the physician community, the Society has worked with the panel to submit a revised framework to CMS that does not collapse the coding levels yet reduces documentation requirements for billing physician services. Importantly, these changes only impact office-based CPT coding and not any other E&M codes.

In a letter to CMS, the Society expressed concern that addressing only office-based E&M codes could have negative consequences and urged CMS to immediately begin to address and bring parity to the rest of E&M coding, in particular the skilled nursing facility (SNF) family of CPT codes. “We believe that E/M outside of the office should be valued in proper relativity to the revised office visit codes. While we don’t have specific recommendations on what the best methodology is, we ask that CMS work in consensus with the full medical community to determine the appropriate value for specific E/M codes. We do not believe there will be a one size fits all solution. We also ask that CMS ensure that documentation guidelines are consistent between the office/outpatient E/M codes and codes describing E/M services in other settings. We urge CMS to do so in a timely manner,” the letter stated.

The Society warned that not addressing the rest of E&M will bring confusion and could impact access to quality care in the nursing facility setting. The Society stated that “providing burden relief and added payment rates to one particular aspect of primary care without parity in [SNF] care could create unintended consequence of less clinicians electing to practice in the SNF.” Thus, it could lead to unintended consequences since the “gap in reimbursement levels continues to widen as CY2020 is proposing a decrease for SNF family of codes. Given that SNF payment is changing to the Patient Driven Payment Model (PDPM) that will require more engagement from clinicians, this lack of parity in payment could pose serious issues in incentivizing clinicians to practice in this setting.”

Physician Licensure

In addition to E&M, the Society also submitted comments opposing CMS’ proposal to revoke licensing for previous violations. CMS proposed these changes it its efforts to address the opioid epidemic. However, the Society urged CMS not to finalize its new proposal to deny or revoke an enrollment for any action a state medical board takes or, alternatively, use a more targeted approach to focus on outliers.

Quality Payment Program

The Society once again expressed concern about CMS’ proposal to increase the weight of the cost category within the Merit-Based Incentive Payment System (MIPS). The main concern remains the lack of appropriate comparison groups for clinicians who practice in PALTC. The Society urged immediate action on its application submitted more than two years ago for a self-selected identifier code. “We have made several requests and inquiries to CMS over the last three years to establish a self-identifier code so that clinicians who practice primarily in this setting can identify themselves as such. We have yet to hear from CMS on its decision regarding our application. We strongly urge CMS to look into this matter immediately as it adversely affects patient access to trained clinicians who take care of the most vulnerable population who have the highest risk of hospital readmission and therefore cost to the Medicare program,” stated the letter.

Likewise, the Society asked CMS to take immediate action to provide PALTC-based clinicians an automatic exemption from the MIPS Promoting Interoperability category to match the exemptions given to clinicians in the hospital and Ambulatory Surgical Center (ASC) settings. “CMS seems to treat clinicians who practice in the PALTC sector differently than any other sector as they must fill out burdensome applications on an annual basis just to avoid penalties that clinicians who practice in other settings do not face. Having these clinicians fill out applications on an annual basis serves no purpose other than spending time on paperwork in lieu of important patient care,” the letter noted.

Finally, the Society supported CMS’ proposal to ease reporting in the MIPS program and align the four categories. However, the Society cautioned that CMS’ proposal to develop the MIPS Value Pathways (MVPs) could create another convoluted process that most clinicians won’t be able to implement  should it become too complicated. The Society urged CMS to provide stability in the program so that practices can implement necessary changes and alignment in the program can come from existing reporting mechanisms rather than creation of new and potentially more burdensome mechanisms.


The Society supported CMS proposals to reduce documentation requirement in chronic care management (CCM) and transitional care management (TCM) coding. Likewise, the Society supported additional codes that would reduce the time necessary to bill the codes as well as new codes for principal care management (PCM). The Society urged CMS to provide clarity for billing these new codes in the SNF setting.


The Society strongly urged CMS to take immediate action to remove the once a month restriction for billing SNF/NF subsequent care codes billed via telehealth. The Society has submitted similar comments in previous proposals, but CMS has yet to act. The Society hopes to work with CMS to provide appropriate safeguards should these changes be implemented.