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Michael Shipley

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Will Payers Follow Medicare’s Lead?

Posted by Michael Shipley on Jul 20, 2021 10:26:29 AM

How E&M Code Changes Will Impact Reimbursement Discussions

By Michael Shipley and Morgan Atkins

Beginning in Q1 2021, significant adjustments went into effect for how payments are calculated for physician services. These changes are the result of modifications to the Calendar Year 2021 Medicare Physician Fee Schedule (MPFS).

These updates will particularly help both primary care providers (PPC) and specialists that bill high volumes of Evaluation and Management (E&M) codes. It will hurt specialists who bill mostly for procedures rather than E&M visits. Consider these specialist examples:

  • An orthopedic surgeon who derives the majority of their income from surgeries, and bills few E&M visits. Their surgery reimbursement will go down, and the increase in E&M reimbursements may not be enough to cover the difference.
  • An endocrinologist who bills a lot of E&M visits for the management of diabetes will benefit from these code changes, receiving more for each E&M billed visit.

As summarized by Gist Healthcare, the implication of these changes will result in “higher pay for some primary care physicians and medical specialists, but reduced payment for many proceduralists.”

Our partners at Ancore Health provided a helpful summary of how reimbursement is calculated, and the impact of this update, in this blog post.

How will Payers Respond?

These changes, which make E&M coded visits more financially valuable, were a significant move by CMS to prioritize primary care and increase the focus on value-based interactions. The clear goal is to encourage more facetime with patients, which can give physicians the opportunity to catch health issues in earlier stages. Quality primary care patient interactions can happen when quantity isn’t the priority.

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