Evaluation and Management Changes
What Breast Surgeons Need to Know
Updated September 27, 2021
Beginning in 2017, the U.S. Centers for Medicare and Medicaid Services (CMS) launched an effort to reduce the documentation burden associated with coding and billing for office and outpatient evaluation and management (E/M) services, both the new and established patient code sets (CPT 99201 - 99205; CPT 99211 - 99215). This effort initially led to a series of proposed changes, which were met with significant pushback from physicians who utilize these code sets. In response, the American Medical Association (AMA) CPT Editorial Panel and RVS Update Committee (RUC) embarked on a collaboration that resulted in the reconfiguration of the office and outpatient E/M documentation guidelines and the RVUs associated with those codes.
After a significant process, CMS finalized these changes (as well as others) as put forward by CPT and RUC with an effective date of January 1, 2021. These changes replaced the current 1997 and 1999 coding and documentation guidelines for office and outpatient E/M codes. However, because of statutory requirements that prohibit CMS from making changes that result in significant overall spending increases, CMS proposed to cut the Medicare Physician Fee Schedule conversion factor to essentially claw back the significant Medicare spending increases that would otherwise result from the increased values it has assigned to the office and outpatient E/M code set (and creation of new companion codes to that code set). This action on its own would have generated a cut in overall 2021 Medicare payments by over ‑6.0% for general surgeons, with similar cuts expected for surgical oncologists.
Just prior to these changes taking effect, Congress passed the Consolidated Appropriations Act, 2021 which provided relief from the January 1, 2021 cut and resulted in 2021 payments to general surgery and surgical oncology to remain roughly the same as payments in 2020. However, a portion of this relief is set to expire at the end of 2021, which would result in a ‑3.75% reduction to the CY 2022 Medicare Physician Fee Schedule Conversion Factor if Congress fails to act.
What action has ASBrS taken?
ASBrS has been active to ensure that your practice is relieved from documentation and administrative burdens, while simultaneously working to ensure that your practice is reimbursed at rates that reflect the resources and skills you expend to serve your patients. ASBrS actively worked to prevent the 2021 policies from generating the cuts estimated for your practice. Examples of this activity include:
- Urging Congress to Prevent Medicare Payment Cuts in 2021
- Endorsing Legislation to Increase Surgery Payments
- Communicating ASBrS priorities for practice support in the current environment to Congress, including the stress that the looming cuts would place on practices.
- Joining the Surgical Coalition in requesting that Congress create a budget neutrality waiver that would prevent the cuts from going into place to pay for the finalized policies.
- Becoming a member of and working with the Surgical Care Coalition, to emphasize the negative health system and patient outcomes that could result from implementing cuts to practices in this environment.
- Urging CMS as part of the official Federal Register public comment process about the concerns ASBrS has regarding the impending reimbursement cuts generated by this policy. View the Society's Comments on the Medicare Physician Fee Schedule 2020 Proposed Rule. View the Society's Comments on the Medicare Physician Fee Schedule 2020 Proposed Rule.
- Engaging our membership in targeted grassroots outreach to House and Senate Leadership.
- Engaging Hill staff during virtual fly-ins.
Given the expiration of the provisions at the end of the year and in order to prevent cuts in 2022, ASBrS continues to seek Congressional action to avoid the cut to the CY 2022 Conversion Factor. We continue to work closely with the Surgical Care Coalition and the American College of Surgeons to effectively communicate the priorities of the surgical community. Additional actions taken by ASBrS include:
- Submitted comments on the Medicare Physician Fee Schedule 2022 Proposed Rule
- Urged Members of Congress via grassroots to sign onto a letter led by Rep. Ami Bera (D-Calif.) and Rep. Larry Bucshon (R-Ind.), which calls for congressional leadership to prioritize averting Medicare Physician Fee Schedule cuts.
- Joined as supporting organization for Bera/Bucshon call to action.
What does this mean for me next?
Although CMS has finalized the policy that generated the cuts to the MPFS conversion factor, ASBrS and its surgical group partners are working tirelessly to pursue a legislative solution that would prevent the cuts from going into effect. Currently, congressional priorities are focused on avoiding a government shutdown and overall federal budgetary concerns, but it is expected that Congress will address other Medicare policies late in 2021. Thus, we continue to push for a fix to the CY 2022 MPFS conversion factor for a late 2021 legislative “vehicle.” ASBrS will provide additional clarity as more information becomes available, including to notify members of congressional engagement opportunities to ensure that patient care is not undermined by the Medicare Physician Fee Schedule’s instability.
- ASBrS Resource Center
- ASBrS Coding & Reimbursement Advisory Group
- CPT Overview: “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes”
- Surgical Care Coalition