Evaluation and Management Codes - Proposed changes for 2019

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Evaluation and Management Codes - Proposed changes for 2019

By Ann Bina, Chief Compliance Officer, CS EYE Compliance Specialists, LLC

Evaluation and Management (99xxx codes) documentation guidelines can be a challenge for any provider. Many hours have been spent learning to document and bill appropriately. Coding inappropriately not only affects revenue for the practice but can also lead to increased payer scrutiny, audits and returned money. The idea of making this process easier has been a point of discussion for years but no real movement was made until recently.

 On July 12, 2018 the Proposed Policy, Payment and Quality Provision Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 was released. Included in the proposed policy is a section specifically related to streamlining the Evaluation and Management guidelines to assist in reducing the provider burden. Highlights of these proposed changes include:

  • Blended payment rate for E&M levels 2-5
  • New add-on codes to reflect:
  • Resources involved in furnishing primary care (i.e., chronic care management, behavioral health integration and prolonged non-face-to-face services)
  • Visit complexity
  • Prolonged visit
  • The ability for practitioners to choose to document using medical decision-making or time instead of applying the current documentation guidelines
  • Time will be allowed even when counseling/coordination of care does not dominate the service
  • Documentation options that allow providers to review and note what is pertinent and/or changed since last visit
  • Allows for review and verification of certain information entered into the EHR by ancillary staff or the patient
  • Allows providers to continue following current guidelines with a minimum documentation requirement for a level 2 service

The proposed policy results in changes to allowed amounts, which will affect your practice’s Medicare revenue. Providers may want to compare their current reimbursement to the following proposed payments, keeping in mind that the final amounts will vary based on the locality of each practice:

  • New Patients

Level 1:          $44.00

Level 2-5:    $135.00


  • Established Patients

Level 1:          $24.00

Level 2-5:      $93.00

The allowed amount for each add-on code outlined above was also included in the proposed policy. Again, the final amounts will vary based on practice locality. These add-on codes are not limited by specialty, but reflect care provided to the patient.

  • Primary Care:                   $5.00
  • Visit Complexity:            $14.00
  • Prolonged Service:       $67.00

The final change in reimbursement will be driven by a proposed multiple procedure payment reduction that would reduce the allowed amount when a 99xxx code is billed with modifier 25, indicating a visit on the same day as a procedure. At this time the proposed change would not affect reimbursement on visits with diagnostic testing performed on the same day.

CMS has confirmed that these proposed changes will not affect the eye exam (92xxx) codes and are proposed only for Medicare fee-for-service patients. Other payers, including Medicare Advantage Plans, will need to confirm the Evaluation and Management guidelines they will follow.

These proposed changes are generating questions from all specialties. CMS is committed to providing education on this proposal by offering printed information as well as scheduled webinars.

In addition, CMS is encouraging providers to submit their comments regarding these proposed changes and several have already voiced their support and concerns. All comments are available for review on this site. CMS will evaluate these comments prior to finalizing any changes.


Evaluation and Management (99xxx codes) will continue to be a challenge for providers, even if changes are made at the Medicare level. It will be important to pay attention to the path commercial payers are taking as it may indicate the need to follow more than one set of Evaluation and Management guidelines in 2019.

Also, following the finalization of the E&M guidelines, which will be published in the Medicare 2019 Final Rule, watch for educational opportunities offered. It’s important that the requirements are understood prior to the January 1, 2019 effective date.

Let’s hope that all changes made are both financially acceptable and implemented by all payers so plans to reduce the provider burden are truly realized.

Source: Center for Medicare and Medicaid Services (CMS)