January 3, 2005

Mark B. McClellan, M.D., Ph.D., Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building, Room 445-G
200 Independence Avenue, SW
Washington, DC 20201

File Code: CMS-1429-FC

Dear Dr. McClellan:

The undersigned organizations are writing in response to the final rule with comment period on “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule for Calendar Year 2005,” as published in the Federal Register on November 15, 2004.  Specifically, we are writing to request that the Centers for Medicare and Medicaid Services (CMS) review the work relative value units (RVUs) of the following evaluation and management (E/M) services during the Five-Year Review of the Medicare Fee Schedule:

99201-99205                 Office visits, new patient
99211-99215                 Office visits, established patient
99221-99223                 Initial hospital care
99231-99233                 Subsequent hospital care
99238-99239                 Hospital discharge services
99241-99245                 Office consultations
99251-99255                 Initial inpatient consultations
99281-99285                 Emergency department services
99291-99292                 Critical care
99301-99313                 Nursing facility services
99321-99333                 Domiciliary services

While our respective interest in these codes varies, we all believe that the work of E/M services has changed significantly since these codes were reviewed during the first five-year review.  As a result, we believe that they are undervalued relative to other services in the Medicare physician fee schedule. 

Background:  How E/M Services Are Currently Valued

Per section 1848(c)(2)(B) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) must comprehensively review “at least every five years” all the relative value units (RVUs) in the Medicare Fee Schedule and make any needed adjustments.  CMS has conducted two “five-year reviews” since the fee schedule’s inception in 1992.  During the first review, a coalition of the principal users of E/M services, including many of the undersigned organizations, urged CMS to review the work RVUs for the E/M codes for the following three major reasons:  

1. The physician work involved in these services had increased since the initial Harvard study of RVUs was conducted.
2. E/M services were undervalued relative to most other procedures.
3. The current E/M codes were never directly surveyed or studied in the Harvard RVU study.

CMS agreed to have the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) review the work RVUs of the E/M codes.  The RUC did so, and in its recommendations to CMS, it noted that it found the arguments made by the specialties and the results of the survey very compelling.  As a result, it recommended increases in the RVUs for many of the E/M services, including office visits, subsequent hospital care, and consultations.  The RUC further noted in its recommendations to CMS:

In addition to the survey results, the RUC’s recommendations are also based on rigorous multidisciplinary review by surgeons and other specialists who share the primary care groups’ views regarding the increase in the work of E/M services in the last five years and the failure of the current RVUs to appropriately recognize the time and effort involved in both intra- and postservice work.  Although primary care physicians are a minority of the RUC members, the RUC’s votes on adoption of the recommendations for these services were nearly unanimous.

Despite this rigorous review and near unanimity among the RUC, CMS, in essence, chose to ignore the RUC’s recommendations and apply its own approach to revaluing the E/M codes.  In explaining its approach, CMS stated, “We believe that maintaining the relationships among the evaluation and management services is important.”  Further, CMS approached the review of work RVUs for the E/M codes in the five-year review with three basic assumptions that it claimed were integral to the original Harvard study and the original 1992 work RVU refinement:

1. All services within a family of E/M services (e.g., office visits) have the same intraservice work intensity; that is, a minute of face-to-face time spent providing a 99211 involves the same amount of physician work as a minute of time spent face-to-face providing a 99215.
2. The intraservice work (i.e., typical) times in the CPT code descriptors are correct.
3. The preservice and postservice work intensity is a fixed percentage of the intraservice work intensity; that is, the amount of work involved in a minute of preservice or postservice time is a fixed percentage of the amount of work involved in a minute of the intraservice (e.g., face-to-face in the office) time.

CMS agreed with those who brought the E/M codes forward during the first five-year review that the intensities (i.e., the amount of physician work per unit of time) of E/M services should be increased to bring them closer to the intensities of procedural services on the physician fee schedule.  CMS also agreed that postservice work of E/M codes had increased over time.  Accordingly, CMS increased the intensities of the intraservice work of the E/M codes by 10% and increased the fixed percentage of intraservice work that represents preservice and postservice work by 25%.  The results were as follows:

CMS proceeded to calculate the work RVUs for each code in each class above using the following formula:

Work RVU = (intraservice work intensity) x (CPT time) x (1 + pre/post percentage of intraservice work)

Thus, although CMS accepted more than 93% of the RUC recommendations, it chose not to use the resulting E/M recommendations made by the RUC and, instead, made a slight, across-the-board increase in the RVUs for these codes.  For other classes of E/M codes (e.g., home visits), CMS either crosswalked to proposed RVUs in one of the classes above or otherwise maintained the (then) current work RVUs because the services had been recently valued (e.g., preventive medicine visits). 

During the second five-year review, no specialty asked for the work of E/M codes to be reviewed, especially as the practice expense component was then under review by CMS and the RUC’s Practice Expense Advisory Committee.  Instead, the second five-year review focused primarily on global surgical services that were claimed to be undervalued. 

Why We Believe the Work of E/M Services Has Changed in the Last Ten Years

I.  Medical Practice Has Changed.

Comparing circumstances now to circumstances ten years ago, when the E/M codes were last subject to review, medical practice has changed considerably.  It has changed even more in the fifteen or more years since the original Harvard work, which still appears to serve as the basis of physician time for these codes.  Changes include: 

1.  A greater expectation that physicians will be proactive in disease prevention as well as diagnosing and treating illness

There is a greater expectation on the part of both patients and payers that physicians will be proactive in disease prevention, health promotion and the early diagnosis and treatment of disease.  This expectation is evidenced by the increasing number of screening services covered under the Medicare program.  In the last ten years, Congress has added the following benefits to the Medicare program:

In 2005, Medicare will add diabetes screening, screening cardiovascular blood tests, and the “Welcome to Medicare” visit to this list.  These benefits represent the application of proven technologies.  Each has been demonstrated in published clinical trials or by expert panel consensus over the last 15 years to have a beneficial effect on the health of the population.  However, they change the nature of medical practice from being reactive to being proactive.  That change has implications for the physician work inherent in medical practice, such as the documentation and scheduling of routine tests, the motivation of patients to undergo tests such as mammograms that are uncomfortable and the follow up of results and patients who fail to make appointments for tests.  It also has implications for both the intraservice intensity and pre- and post-service time involved.¹ 

2.  Additional documentation requirements added to physician work

The implementation of the 1995 and 1997 Medicare E/M documentation guidelines has increased documentation demands related to stand-alone E/M services.  These guidelines did not exist the last time the E/M codes were reviewed.  This adds to the physician work of E/M services relative to other services, which are not subject to the documentation guidelines.  Even global surgical services, which include an E/M component, are unaffected by the advent of the documentation guidelines, since E/M services in the global period are not separately reported.  

Medicare is not the only one requiring increased documentation.  The Joint Commission on the Accreditation of Healthcare Organizations has also increased its documentation requirements as it relates to hospital visits. 

The advent of electronic health records, while facilitating access to patient information, has created new work for clinicians.  Medication and problem lists must be accurately maintained by providers.  Furthermore, with the multiple medications now required by many patients, monitoring for drug-drug interactions becomes an essential component for quality care.

The impact of increased documentation requirements on intraservice work and pre- and post-service time cannot be overestimated.  A survey of clinical oncologists, backed up by activity logs and site visits, revealed that more than 97% of survey respondents reported an increase in documentation (averaging 1.4 hours per day) and 77% reported an increase in work hours because of documentation in the previous five years.² 

3.  An increase in the complexity of data to be evaluated and care to be managed

Evaluation and management of patients involves integrating much more information than it did ten years ago, which increases the intraservice intensity of E/M services and increases the pre- and post-service time involved.  As noted below, there are more informed consumers who want to and should be actively involved in decision-making, and they bring more information with them to their visits. 

There is also more polypharmacy.  For example, heart failure programs expect the concurrent management of 5-7 medications, and the JNC 7 hypertension recommendations³ support 2-4 medications for good control. 

Further, there has been an explosion in the number of clinical guidelines that are good examples of what is considered optimal care.  Add to this all of the new diagnostic and screening tests that have come into existence over the past ten years, with their corresponding results to be considered and follow-up on as required, and it is no wonder that the complexity of care of even the most common conditions (e.g., diabetes) has increased.^4,5 

We also note that the benefits of the successful co-management of the concurrent conditions of hypertension, diabetes, lipid abnormalities, and obesity have been demonstrated in clinical trials.  Patients successfully treated in all areas had a 53% lower risk for cardiovascular disease.⁶  The application of the proven benefits of currently available therapies requires both intense and effective direct patient contact and expanded pre- and post-visit attention.  The value of such continuous effective care needs to be recognized by appropriately valuing E/M services.  

4. Patients presenting to the office with a greater expectation of participating in medical decision-making and with more information from the Internet and lay press.

There is a new paradigm of medical decision-making that has evolved over the last ten years.   The doctor and patient are in a collaborative relationship, each with unique and important information components.  Decisions are now “shared,” which is to say that the hierarchy of physicians instructing patient has been replaced by a more equal doctor patient discussion around diagnostic testing and treatment strategies.^7,8 

Additionally, ten years ago, the Internet and World Wide Web were a novelty accessed by few and used effectively by even fewer.  Today, the Internet and World Wide Web are part of everyday life, accessed daily by millions of Americans.  As with any technological advance, the growth of the Internet has both positive aspects (i.e., more information available more readily to more people) and negative aspects (i.e., more misinformation available more readily to more people).  Patients today routinely present to the office with information that they have gleaned from the Internet and with questions about the veracity and applicability of that information in their circumstances. 

As a result, counseling and coordination of care that physicians do within the context of E/M services requires more time and better preparation than ten years ago.  Physicians must be more mindful of the popular impressions and expectations, both good and bad, created by the mass media and developed on the Internet.

5.  The advent of online communications with patients

Ten years ago, patients did not typically communicate with physicians by e-mail or other online means.  They either called the office or came in for a visit.  Today, e-mail is ubiquitous, and patients routinely communicate with physicians through this medium.  Further, patients are interested in getting e-mail updates about new advances in treatment.  Patients are also interested in virtual visits for simple and chronic medical problems and for following chronic conditions through virtual means.^9,10  As growth and communication via the Internet continue, providers of E/M services must adapt to meet their patients’ needs.  CMS did not account for online communication with patients when the E/M codes were evaluated ten years ago.  It remains unaccounted.   

6.  A greater role for genomics in the evaluation and potential management of patients

Ten years ago, the human genome had not been mapped.  Now, it has, and the information generated is referred to by some as the “new anatomy.”¹¹  With the mapping and sequencing of the human genome, medical professionals from essentially all specialties have turned their attention to investigating the role genes play in health and disease, and genetic disease represents an important part of medical practice.  Diagnosing a genetic disorder not only allows for disease-specific management options but also has implications for the affected individual's entire family.  As such, a working understanding of the underlying concepts of genetic disease is necessary for today's practicing physician, and routine clinical practice requires integration of these fundamental concepts for use in accurate diagnosis and ensuring appropriate referrals for patients with genetic disease and their families.¹² 

In addition, genomic information will become integral to the selection of treatment in a variety of disease conditions, adding a new dimension to disease management.¹³  All of this expands the knowledge base required for each E/M service since this information must be integrated with the traditional cognitive base.

7.  Environmental Changes in the Emergency Department

Emergency department (ED) codes, unlike the majority of other E/M codes are not time based and therefore some of the points addressed elsewhere in this letter do not apply.  However, over the past ten years there have been a number of environmental issues, such as the percentage of higher acuity patients, increased volume, increased documentation requirements, and higher malpractice risks, that have increased the work involved in providing the typical emergency department E/M service. Due to the recent decline in the number of operating emergency departments, the volume of patients being served by the remaining existing facilities has increased.  The CDC reports that the number of ED visits between 1992 and 2002 increased by 23%, from 89.8 million to 110.2 million, while the number of hospital EDs in the United States decreased by 15% during the same period. Uninsured patients using the emergency department as their source of primary care also contributed to the increase in volume of patients.  According to the CDC Advance Data Reports, National Hospital Ambulatory Medical Care Survey: Emergency Department Summary, the percentage of uninsured patients rose from 13.8 % (12.4 million) in 1992 to 14.5% (16 million) in 2002, the last year for which data is available. This translates to a 29% increase in the number of uninsured patient visits in the ED over the past ten years.  In September 2003, CMS released clarifying policies related to the responsibilities of facilities with patients presenting under the provisions of the Emergency Medical Treatment and Labor ACT (EMTALA), which decreased the ability of physicians working in the emergency department to locate a specialist to provide patients with necessary specialty care.  The delay in finding an on-call specialist physician requires more effort and intensity from the emergency physician in evaluating and caring for a patient. These factors combined with the nationwide hospital crowding problem means that patients are being boarded in the emergency department, increasing the work associated with providing care for the typical ED encounter.

II.  The intensity of E/M services has increased over time. 

Support for the increased intensity of E/M services, particularly office visits, may be found in the results of the National Ambulatory Medical Care Survey.  Data from this survey published by the Centers for Disease Control and Prevention in 2003 reflect increasing complexity and intensity of physician work in office practice from 1992-2002.  Patients were older, had more complex diagnoses, more discussion of treatment and more mention of drugs used in treatment in 2002 than was the case in 1992.¹⁴ 

Yet, coding patterns for office visits have not changed substantially in that time.   In its August 2002 report to the CPT Editorial Panel, the CPT E/M Services Work Group, of which CMS was a part, referenced an analysis of Medicare claims reporting data for E/M services within selected specialties from 1992-2000.  The aggregate data, provided by CMS staff, suggested stability in use of the E/M visit codes by physicians.  In particular, the data showed a stable pattern in reporting of services by major users of E/M codes, such as internists, family physicians, neurologists, and cardiologists,.  This suggests that physicians have not attempted to capture the increased intensity of their work by choosing higher level E/M codes to report their services.  Though the intensity of a given level of E/M service has increased since the last time these codes were reviewed, physicians have maintained internally consistent relative value of service (i.e. the proportion of visits at each level as remained stable though there is clearly more work involved at each level).  

III.  Hospital length of stay has changed.

Hospital length of stay has decreased in the last ten years.  According to Medicare data, in 1990, the average length of stay in all short-stay hospitals was 9.0 days.  In 2001, the corresponding length of stay was 6.0 days.^15,16 

Shortened length of stay has been accomplished with the combined efforts of hospitals, insurance carriers, and home care service companies and the effective and rapid use of new diagnostic tests and powerful new therapies.  The orchestration of all this care, however, requires the intense efforts of physicians in the inpatient setting. 

Some of this care is provided by hospitalists.  The emergence of the hospitalist as a specialist in inpatient medicine is another change in medical care that has occurred in the last ten years.  Hospitals, health systems and health maintenance organizations have used hospitalists as a means to reduce length of stays and more efficiently manage inpatient care.¹⁷  Their success in doing so is unclear.¹⁸  However, to the extent that the use of hospitalists has had an impact on hospital length of stay and medical practice, that impact on the work associated with E/M services remains unmeasured. 

The impact of shorter lengths of stay is compounded by and compounds other changes that we have described.  For instance, we believe that patients are more complex upon admission due to such factors as more chronic illnesses and polypharmacy.  In turn, shorter lengths of stay may mean that patients are sicker and more complex on discharge, which potentially affects both hospital discharge services and the complexity of services in the outpatient setting.  All of this has implications for the work of E/M services in the inpatient setting which must, therefore, be reviewed during the five-year review. 

Other Reasons for Reviewing the E/M Codes

I.  Relative Intensity of E/M

During the first five-year review, CMS agreed that the E/M services were undervalued relative to most other services, based on a comparison of intensity (i.e., intraservice work per unit of time (IWPUT)).  IWPUT is calculated by dividing the work RVUs attributable to the interservice period by the intraservice time in minutes.  We believe a comparison of current IWPUT for E/M codes and other services will establish that the same situation of relative undervaluation exists now. 

For instance, the intensity (i.e., intraservice work per unit of time) for office visits and hospital visits, as set by CMS, is 0.031.  Compared to other services, this is disproportionately low.  For instance, a point of comparison during the first five-year review was code 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm).  The IWPUT for 12002 is 0.053, which is 71% greater than an E/M service.  In another instance, the IWPUT for 65205 (Removal of foreign body, external eye; conjunctival superficial) is 0.0972, which is more than 3 times the intensity of an E/M service.  Even x-rays are considered more intense; the IWPUT for a radiological exam of the knee (73560) is 0.056.  Both 65205 and 73560 are on the RUC’s Multi-specialty Points of Comparison.  In fact, it is hard to find any other services, no matter how technically simple or non-invasive that have less physician work per unit of time than E/M services, even though E/M services, especially at high levels, involve the concurrent management of multiple physical and mental health problems and medications. 

II.  Typical Visit Length

The literature suggests that physicians are spending more time during visits rather than less.  Both National Ambulatory Medical Care Survey (NAMCS) and Socioeconomic Monitoring Survey (SMS) data show an increase in average length of visit over time.  For instance, the NAMCS data show that length of visit increased from 16.3 minutes in 1989 to 18.3 minutes in 1998, a 12% increase.  The SMS data show an increase over the same time period from 20.4 minutes to 21.5 minutes.¹⁹  Yet, CMS currently values E/M codes based on the typical times listed in CPT, which have not changed since their inception.  To the extent E/M services involve more time than they did ten years ago, the current RVUs undervalue those services. 

III.  Pre- and Post-Service Times

The pre- and post-service times attributable to E/M services do not appear to be surveyed times, and it is not apparent that the first five-year review placed as much emphasis on surveying other elements of work as it did on surveying intraservice work.  Further, as noted above, changes in medical practice over the last ten years have had an impact on pre- and post-service time involved in E/M services.  Therefore, we believe that the pre- and post-service times currently attributable to E/M services are unreliable and provide another reason to examine the E/M codes during the upcoming five-year review. 

Conclusion

In conclusion, we believe that the E/M services listed below are not appropriately valued for the following reasons:

• The intensity, complexity and duration of intraservice medical care have increased in the past ten years.
• The intensity, complexity and duration pre- and post-service time have expanded.
• The work per unit of time for E/M services is less than the work per unit of time for almost any other service.

We do not know the magnitude by which E/M services are undervalued or whether or not the undervaluation is uniform across E/M services.   However, we believe that it is imperative for CMS, working with the RUC and the specialty societies, to find out.  Accordingly, we respectfully ask that CMS subject the following E/M codes to scrutiny as part of the current five-year review:

99201-99205                 Office visits, new patient
99211-99215                 Office visits, established patient
99221-99223                 Initial hospital care
99231-99233                 Subsequent hospital care
99234-99236                 Hospital observation or inpatient care (same day discharge)
99238-99239                 Hospital discharge services
99241-99245                 Office consultations
99251-99255                 Initial inpatient consultations
99281-99285                 Emergency department services
99291-99292                 Critical care
99301-99313                 Nursing facility services
99321-99333                 Domiciliary services

Thank you for your time and consideration of this request.  We look forward to working with CMS to ensure the continued access to appropriate physician services. 

Sincerely,

American Academy of Allergy Asthma and Immunology
American Academy of Family Physicians
American Academy of Home Care Physicians
American Academy of Neurology
American Academy of Pediatrics
American Association of Clinical Endocrinologists
American College of Allergy Asthma and Immunology
American College of Chest Physicians
American College of Emergency Physicians
American College of Physicians
American Diabetes Association
American Geriatrics Society
American Medical Directors Association
American Nurses Association
American Osteopathic Association
American Psychiatric Association
American Society of Anesthesiologists
American Society of Clinical Oncology
American Society of Hematology
American Thoracic Society
Endocrine Society
Infectious Diseases Society of America
Joint Council of Allergy Asthma and Immunology
Renal Physicians Association
Society of Critical Care Medicine
Society of General Internal Medicine
Society of Hospital Medicine

References

1. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL, "Primary care: is there enough time for prevention?," Am J Public Health. 2003 Apr;93(4):635-41. 

2. Einhorn, Lawrence H., et. al., “American Society of Clinical Oncology 2001 Presidential Initiative: Impact of Regulatory Burdens on Quality Cancer Care,” J Clin Oncol 20:4722-4726

3. Hypertension 2003; 42: 1206-1252.

4. Richard W. Grant, Paul A. Pirraglia, James B. Meigs, and Daniel E. Singer, Trends in Complexity of Diabetes Care in the United States from 1991 to 2000, Archives of Internal Medicine, May 24, 2004, (Arch Intern Med 164:  1134-1139)

5. Konen JC. Comment on:  N C Med J. 2003 Mar-Apr;64(2):73-9.  Why are we surprised by our failures? The bewildering complexity of diabetes care. 3: N C Med J.  2003 Mar-Apr;64(2):80-2.

6. NEJM 2003: 348: 383-393.

7. Frankel RMRelationship-centered Care and the Patient-Physician Relationship.J Gen Int Med 2004; 19:1163-1165.

8. McNutt RA Shared Medical Decision MakingJAMA 2004; 292: 2516-2518.

9. Grover F Jr, Wu HD, Blanford C, Holcomb S, Tidler D. Computer-using patients want Internet services from family physicians.  J Fam Pract.  2002 Jun;51(6):570-2. 

10. Couchman GR, Forjuoh SN, Rascoe TG. E-mail communications in family practice: what do patients expect?  J Fam Pract.  2001 May;50(5):414-8.

11. Whittaker LA. Comment in:  J Fam Pract. 1992 Sep; 35(3):256-8. The implications of the Human Genome Project for family practice.  J Fam Pract.  1992 Sep;35(3):294-301.   

12. Ensenauer RE, Reinke SS, Ackerman MJ, Tester DJ, Whiteman DA, Tefferi A Primer on medical genomics. Part VIII: Essentials of medical genetics for the practicing physician.  Mayo Clin Proc.  2003 Jul; 78(7):846-57.  

13. Paik S, Shak S, Tang G et al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. NEJM 2004; 351: 2817-2826. 

14. Donald Cherry, M.S., Catherine W. Burt, Ed.D, and David A. Woodwell; Advance Data from the Vital and Health Statistics:National Ambulatory Medical Care Survey (NAMCS) 2001 Data Summary, Number 337, August 11, 2003, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.www.cdc.gov/nchs/data/ad/ad337.pdf

15. Source:  2003 CMS Statistics reference booklet.

16. Carol J. DeFrances, PhD. and Margaret J. Hall, Ph.D., Advance Data from Vital and Health Statistics:  2002 National Hospital Discharge Summary, Number 342, May 21, 2004, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.

17. Molinari C, Short R. Effects of an HMO hospitalist program on inpatient utilization.  Comment in:  Am J Manag Care. 2001 Nov;7(11):1101-4.  Am J Manag Care.  2001 Nov;7(11):1051-7. 

18. Robert M. Wachter, MD, Hospitalists in the United States—Mission Accomplished or Work in Progress? New England Journal of Medicine, Volume 350:1935-1936, May 6, 2004, Number 19. 

19. David Mechanic, Ph.D., Donna D. McAlpine, M.A., and Marsha Rosenthal, M.A. Are Patients’ Office Visits with Physicians Getting Shorter?  New England Journal of Medicine, January 18, 2001 (Vol. 344, No. 3).