Significant Proposed Medicare Rule Changes for 2019

The proposed Medicare rule changes for 2019 may very well change the way you practice, if the suggested changes are accepted. The final rule will be published in early November.

You can down load the entire document from through the following link for your reading pleasure if you so desire.


In this article we will address some of the highlights of the proposed changes

Key changes of Interest are listed below

  • A significant decrease in the amount of documentation required for E & M codes
  • Single payment for all E & M established patient visits
  • Single payment for all E & M new patient visits
  • Payment for some telemedicine;
  • Decrease payment for the 25 modifier;
  • Change in documentation requirements for time based E & M services;
  • Changes in payment for some part B drugs;
  • Potential slight increase in payment for office cystoscopy’s


E & M documentation guidelines and the payment for E&M services


The proposed changes remind us of a favorite old saying “be careful what you want you might get it”.  If adopted, you will no longer have to record detailed information that is not pertinent to your office and outpatient E/M services (99201-99215), nor will you have to document physical observations and perform physical exams that are not medically necessary. Copying previous encounters should be a thing of the past.  How often in the past have you wished that you did not have to spend the time documenting information that was not medically necessary?


The proposed changes to documentation requirements:

  • In order to charge an E&M visit you will need to meet the documentation requirements of a level II visit as outlined in the 1995 / 1997 guidelines;
  • You have a choice: medical decision making (MDM), time, or keep using the 1995 or 1997 guidelines, as a basis to determine the appropriate level of E/M visit;
  • Allow any E & M visit to be charged based on time;
  • CC and HPI can be entered by staff or patient if reviewed by practitioner;


Proposed changes to payment for outpatient E & M services

  • Pay a single rate for levels 2 through 5 of office and other outpatient, new patient E & M services
  • Pay a single rate for levels 2 through 5 of office and other outpatient established patient E & M services
  • Pay 50% for the E & M services with –25 modifier or the procedure, whichever is the lesser of two.
  • Add-on G-codes for certain E & M visits

The details of the proposals provide us with some pleasant surprises.

The proposed rule verbiage is confusing, however we will try to simplify. The documentation requirements have been reduced, whether you choose time, medical decision-making or the current ’95 or ’97 guidelines for reporting purposes. Practitioners would only need to meet documentation requirements currently associated with a level 2 visit for history, exam and/or MDM.

For example, to qualify for the established patient E & M visit, one would have to document only 3 elements on the history of present illness, no review of systems or past, family, social history, for a problem not requiring active treatment. Even though the requirements have been reduced, CMS makes it clear that their expectation is that practitioners continue to perform and document E/M visits as medically necessary for the patient, to ensure quality and continuity of care. What a novel idea: “document only what you think is medically necessary for the patient”.

Current CPT codes would continue to be charged according to the level of Service you think you performed.

The proposed option for billing based on time is a blend of the times for levels two through five, 31 minutes. Then apply the rules established by CPT in which time documented for each code is an average rather than threshold time. Therefore the time required to charge the established patient combined code would be 16 minutes.

(For those of you who’ve been fighting with compliance departments & coders, this proves that the current times are “average” times and not “threshold” times)

Single payment for all E and M services (Levels 2 through 5), for a New Patient would be $135 and for an Established Patient, $93. The payment will be the same regardless of which method of documentation you choose to use.

The following tables were included in the proposed rule illustrating the payment plan.




CY 2018 Non-facility Payment Rate

CY 2018 Non-facility Payment Rate under the proposed Methodology
99201 $45 $44
99202 $76  


99203 $110
99204 $167
99205 $211




Current Non-facility Payment Rate Proposed Non-facility Payment Rate
99211 $22 $24
99212 $45  


99213 $74
99214 $109
99215 $148


CMS estimates that urologist will receive less than a 3% increase if the proposed rules are adapted


CMS is proposing to create two new HCPCS.


  • GPC1X Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services (Add-on code, list separately in addition to an established patient evaluation and management visit)
  • GCG0X Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care (Add-on code, list separately in addition to an evaluation and management visit).


GCG0X will be an add-on code to be charged with the appropriate standalone E&M code for visits. The code will pay about $14 in addition to the new common payment. The final rules governing when this code can be used will be very important as we look at the impact of this change. Urology was named as one of the specialties that qualify for the use this code.


Pay 50% for services with E & M –25 modifiers

CMS is proposing to cut the payment for the lower valued code either the E/M code or the procedure code reported by 50%.

Urologist should send the message to CMS during the comment period, explaining that an E & M service, that results in performing a cystoscopy that same day, are two services with minimum overlap in time and resources.

Payment for Telemedicine,


CMS calls the paymentcoverage for a Virtual Check-in visit”


This service would be billable when a physician or other qualified health care professional has a brief non face-to-face communication with a patient via technology, which is not accompanied by a surrounding office visit.


GVCI1 Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.


The Code description provides significant guidance as to when the service can be reported.


Endoscopy Practice Expense Adjustment


CMS has acknowledged that essential sterilization equipment was left out of the PE calculation in 2017. The equipment and the associated time for the process will be added back into the Practice Expense value. This should provide at least a little gain in the value of the 52000 codes for 2019.


In Summary


The proposed rule changes will provide a welcome relief in documentation requirements. Single payment for office visits will receive a lot of resistance from the medical subspecialties and the others that see a high number of complicated patients. (That same argument is the reason we ended up with five levels of E & M codes, and the complicated documentation system in the beginning.)


Offices that currently bill predominately level IV & level V codes will take an overall hit in payments; the offices that average a level III, will receive a “bonus”


The bottom line:

The rules may not be adopted as proposed, but in reading the comments and listening to CMS webinars, we feel that the documentation requirements will be significantly reduced and the payment system simplify. The end results will be a less cluttered patient record and more time to see patients.

We will continue to keep you informed in future articles and encourage you to consider getting involved in support or opposition to these proposals. CMS is listening.

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Dr. Ray Painter, after owning and running a urology practice with 3 partners for 25 years, became a nationally recognized coding, billing and practice management expert. He has delivered hundreds of seminars for medical specialty societies, regional and state medical societies, The PRS Network, Pharmaceutical, Device Companies and many other entities.