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The AAN Responds to Proposed Fee Schedule Cuts



DR. NEIL A. BUSIS: “This is something that has been lurking around for a long time. We have been given a big challenge by CMS, and I think we can meet the challenge, which requires coming up with a consensus, but its going to take time to work it out.”

The AAN has advocated to CMS that it delay implementing the E/M coding changes proposed in the 2019 Physician Fee Payment Schedule.

Alarmed by the federal proposal to fundamentally change the way the Medicare pays for office visits, the AAN is seeking to delay implementation until a better approach can be worked out.

As reported in the cover article, “Why the 2019 CMS Proposed Fee Schedule Could Portend Financial Catastrophe for Neurology,” the Centers for Medicare & Medicaid Services (CMS) proposal to collapse the number of payment levels for office visits from five to two could have a substantial and dire financial impact on the mission and financial viability of academic neurology and community-based neurology practices.

The proposed changes are part of the CMS attempt to reduce physician paperwork by simplifying the documentation requirements for evaluation and management (E/M) visits, said Marc Raphaelson, MD, a neurologist at the Veteran Administration Medical Center in Martinsburg, WV.

CMS is not trying to devalue neurologists' work, said Dr. Raphaelson, who helped write the AAN's official comments responding to the proposal in a September 4 letter; rather, its proposal reflects unintended consequences of its plan to simplify life for physicians.

“They say it's inadvertent, and I really do believe them,” said Dr. Raphaelson, a member of AAN Coding Subcommittee and the Academy's representative on the RVS Update Committee (RUC). “They are trying to respond to doctors' complaints about administrative burden, but the way they chose to do it has consequences that they have not fully thought through.”

Neil A. Busis, MD, FAAN, a member of AAN Coding Subcommittee and the Academy's alternate on the American Medical Association (AMA) Current Procedural Terminology (CPT) Advisory Committee, said the CMS proposal gives new urgency to figuring out a better way to pay for office visits. Various efforts to do so in the past have failed to get off the ground.

“This is something that has been lurking around for a long time,” Dr. Busis said. “We have been given a big challenge by CMS, and I think we can meet the challenge, which requires coming up with a consensus, but it's going to take time to work it out.”

Dr. Busis thinks CMS acted hastily in making its proposal without input from physician groups or small-scale experimentation. “This is the biggest E/M change in a generation and yet there were no pilot projects, no demonstration projects,” he said. “It's very unsettling.”

In the comments submitted to CMS, the Academy asked for a time-out. “This change in physician payment is too important for CMS to move forward with such a limited time for feedback and analysis,” the letter from the AAN said. “We request CMS reconsider their rule as currently written and engage in consultation directly with specialty societies, including the AAN, on future proposals.”

Indeed, the AAN has communicated the urgency of response to the proposal in a series of online and email communications, and the issue has clearly hit a nerve with members. The E/M proposal was discussed at a number of advocacy events as a part of Neurology off the Hill. The AAN posted information about the proposal on the homepage of, generating a lot of Web traffic (22,997 impressions) and 444 click-throughs to the AAN Medicare page.


The current five-level E/M coding system dates back more than two decades ago when an American Medical Association-led committee developed descriptions of various levels of complexity for new-patient and established-patient visits. In 1995, the Medicare program published documentation guidelines for each level, requiring physicians to justify billing for a specific level of visit. Those guidelines were updated in 1997 and have been used ever since.

Regulators and physicians alike agree that the guidelines have become a problem. Because physicians must perform certain tasks to bill for a high-level visit, they feel they waste time doing and documenting irrelevant work that takes time away from the challenging medical situation at hand.

“If I'm seeing someone for a flare-up of multiple sclerosis, I have to be sure to document a full review of systems — how is their hearing and do they have a cough? — if I'm going to bill for a high-level visit for this difficult patient, even though these questions may not be relevant to this particular visit,” Dr. Raphaelson said.

Documentation became easier with the advent of electronic medical records, which allow physicians to autofill or copy-and-paste visit details to support specific billing codes. That — along with other factors — has led to more high-level visits being billed to Medicare.

“People have learned how to use the system to document complicated visits,” he said. “Over the course of the last 10 years in particular, more visits are Level 4 and 5 visits, where there used to be a lot more Level 2 and 3 visits.”

From the CMS perspective, collapsing E/M payment to a single rate reduces physicians' documentation burden and the government's need to audit patient records to make sure billing codes are supported by proper documentation, Dr. Raphaelson said.

Although AAN leaders like the offer of reduced documentation, the trade-off of lower pay for the most complex visits is not worth it, Dr. Raphaelson said.

“If we are going to get the reduction in administrative burden that we want, then we have to find an alternate way for Medicare to pay for our services,” he said.


But there's no time for an alternate way to be vetted and ready to go by Jan. 1. So AAN leaders are hoping CMS agrees that its own payment proposal should be put on hold so that physician groups can help come up with a better idea.

In addition to its own official response, the Academy is working with the American Medical Association's CPT/RUC work group on E/M; a multispecialty Coalition for Patient-Centered Evaluation and Management Services; and another group co-led by the AAN and the American College of Rheumatology (ACR).

“We recently worked closely with ACR to put together a patient and provider group letter opposing the E/M payment cuts that was signed by 133 organizations,” Daniel Spirn, AAN senior regulatory counsel, said in an email. The sign-on signatures comprised 37 patient groups (not all directly related to neurology), 33 neurology-related groups, and 63 other specialty societies not related to neurology.

“The message is loud and clear,” Spirn said. “CMS should not move forward with these E/M payment cuts as currently proposed in the fee schedule.”

However, not all physician groups share that message. Physicians who have routinely billed for Level 2 and Level 3 visits would benefit from CMS' proposed changes.

“There are a number of doctors who find it very appealing,” Dr. Raphaelson said. “There is not going to be a uniform voice from the medical community because, under this proposal, there are some clear winners and some clear losers.”


•. Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program. Federal Register, July 27, 2018.