CMS Decides Not to Reduce Reimbursement for Complex Patients in 2019 PFS

Allison Inserro

This story has been updated. 

CMS said it responded to complaints about its calendar year 2019 Medicare Physician Fee Schedule (PFS)—which it finalized today—and will not collapse 5 evaluation and management (E/M) documentation and billing codes down to 2, which had drawn an outcry from some medical associations that their care for complex patients would be shortchanged.

CMS said it will retain a code for level 5 medically complex patients and will also delay the implementation of the collapse of the payment codes for an additional 2 fiscal years while it continues to work with stakeholder groups on the issue.

The agency also added telehealth codes.

CMS said it was making the changes to documentation, coding, and payment to reduce administrator burden.

One of those stakeholder groups, the American Medical Association (AMA), released a statement saying it was “grateful” for the decision not to change the coding system at this time. The AMA convened a workgroup earlier in the year to work with CMS on the issue.  

“With physicians facing excessive documentation requirements in their practices, it is relief to see that the Administration not only understands the problem of regulatory burden but is taking concrete steps to address it,” Barbara L. McAneny, MD, president of the AMA, said in a statement. “Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records.”

The code for complex payments will remain the same at $148.

Another stakeholder, the Community Oncology Alliance (COA), also indicated it was largely pleased with the final rule,  saying that,  "CMS Administrator Seema Verma and staff have largely listened and responded to feedback, resulting in a final rule that for the most part is good for patients and their providers." However, COA said it remains "concerned about what will still be an inappropriately large cut to reimbursement for the administration of chemotherapy. Additionally, CMS’ decision to arbitrarily lower reimbursement for the introduction of new cancer drugs to wholesale acquisition price (WAC) plus 1.35% is seriously misplaced because it will only fuel manufacturers to increase their list prices (WAC) of expensive cancer drugs."

CMS cut Part B drug payments from WAC plus 6% to WAC plus 3%.

Verma said the changes were necessary in order to move to value-based care, but said the agency is willing to keep working with stakeholders. "We know that this will have a tremendous impact on many doctors in America," she said.

Patient and provider groups raised an outcry earlier this summer at the proposed changes to the E/M codes. In response today, CMS said it will continue current coding practices for 2019 and 2020.

In 2021, CMS said it will pay a single rate for E/M office/outpatient visit levels 2 through 4 for established and new patients while keeping the level 5 payment the same.

Clinicians would have a choice to use either medical decision-making (MDM) or time for documentation.  CMS will also create a new “extended visit” add-on code for use only with E/M office/outpatient level 2 through 4 visits. 

The agency also said it will not finalize rules that doctors and others objected to, including those that cut payment when E/M office/outpatient visits were given on the same day as procedures, one that set separate coding and payment for podiatric E/M visits, and one that standardized the allocation of practice expense resource value units for the codes that describe these services. 


CMS created new codes for "communication technology-based services"—one for virtual check-ins, and one for remote evaluation of recorded video and/or images submitted by an established patient.

It also is expanding the use of telehealth for opioid use disorders and other substance use disorders.

Print | AJMC Printing...