The American Academy of Ophthalmology and American Society of Retina Specialists joined with the American Medical Association and about 170 other medical groups in sending a letter to Centers for Medicare and Medicaid Administrator Seema Verma voicing their opposition to the Trump administration’s proposal to collapse payment rates for office visit services for new and established patients from eight to two. Now, CMS is weighing whether to implement those changes for the 2019 fiscal year or hold off until 2020.

The AMA sent the letter before the comment period closed on September 10. CMS has proposed adopting the new rules for January 1, 2019, but solicited comments on delaying their implementation for a year. The proposed rules are part of a larger CMS initiative called “Patients Over Paperwork” aimed to streamline providers’ documentation requirements and modernize Medicare payment policies to accommodate access to virtual care. 

CMS claims the proposed changes to the Physician Fee Schedule (PFS) would save individual clinicians an estimated 51 hours per year if 40 percent of their patients are in Medicare, and changes in the Quality Payment Program would collectively save clinicians an estimated 29,305 hours and approximately $2.6 million in reduced administrative costs in 2019.

“There are a number of unanswered questions and potential unintended consequences,” and the proposed rates “could hurt physicians and other health care professionals in specialties that treat the sickest patients.” — Medical Groups' Letter

The American Society of Interventional Pain Physicians—one of the medical organizations that signed the letter to Ms. Verma—reports the change in the payment structure for evaluation and management (E/M) services would mimic the United Kingdom system, using one payment for most levels of services, aiming to avoid upcoding and downcoding.

Among the changes CMS has proposed are:

• Blend payment for five levels of new patient office visits (99202 to 99205) into one payment of $135 instead of $76 for Level II to $172 to Level V. Established patient office visits (99212 to 99215) would be blended to be paid at $93 instead of $45 for Level II and $148 for Level V.

• Create new codes to provide add-on payments to office visits for specific specialties ($9) and for primary care physician ($5).

• Allow practitioners from the same group and specialty to bill for same-day visits if medically necessary, ICD-10 Monitor reports. Office visits on the same day as a procedure with no global period would be paid at a 50-percent discount when billed with modifier -25.

• Pay physicians for their time when they check in with patients via telephone or online, and pay physicians for their time to review a video or image sent by a patient to assess whether a visit is needed.

• On the documentation side, change the required documentation of the patient’s history to focus only on the interval history since the previous visit.


• No longer require practitioners to personally document patient history, but allow them to review history entered by staff or the patient and indicate they verified it.

• Remove the need to justify a home visit vs. an office visit.

The AMA and medical societies support the proposed documentation rules. “Implementation of these policies will streamline documentation requirements, reduce note bloat, improve workflow and contribute to a better environment for health care professionals and their Medicare patients,” the letter notes

However, the medical groups aren't so warm to the proposed payment rates, noting “there are a number of unanswered questions and potential unintended consequences” and that “it could hurt physicians and other health care professionals in specialties that treat the sickest patients.” Another argument they invoked against the rule change: CMS factored the issue of multiple same-day services into prior valuations of the affected codes. “The proposal also has significant impact on certain services, such as chemotherapy administration, that may be an unintended consequence of altering the current practice expense methodology to accommodate the proposal,” the letter states

The signature organizations expressed their support for an AMA-led working group to the E/M coding and payment issues in time to implement the 2020 Medicare PFS.

Large Study Adds to Evidence That Lower Cholesterol Means Lower DR Risk 

The evidence that statins and fenofibrate to treat high cholesterol in patients with type 2 diabetes may have a protective effect against diabetic retinopathy received a significant boost with the publication of a large study in Japan that found a 23-percent reduction in risk among patients on lipid-lower drugs.

The study, led by Ryo Kawasaki, PhD, of Yamagata University in Japan, evaluated two cohorts of about 85,000 patients with type 2 diabetes who were taking glucose-lower drugs at baseline. 

In the first cohort of 69,070 patients without DR at baseline, 49,744 (72 percent) were on some form of lipid-lowering therapy. In the second cohort of 15,738 patients with DR at baseline, 10,499 (66.6 percent) were on such therapy. Among the types of statins used, 20.9 percent were on standard statins (simvastatin, pravastatin and fluvastatin) and 79.1 percent on strong statins (atorvastatin, rosuvastatin and pitavastatin). The proportion of prescriptions for bezafi brate and fenofi brate was 54.4 and 45.5 percent, respectively. 

In the fi rst cohort, the rate of developing DR in three years among those on lower-lipid therapy was 7.4 percent (n=1,423) vs. 11.4 percent (n=5,5687) for those not taking the drugs. Among the second cohort, the treatment burden for DR was about one-third lower for the group on lipid-lowering drugs, 1.9 percent (n=98) vs. 3 percent (n=320).

Novartis and Pfizer Japan provided research grants to support the study.

1. Kawasaki R, Konta T, Nishida K. Lipid-lowering medication is associated with decreased risk of diabetic retinopathy and the need for treatment in patients with type 2 diabetes: A real-world observational analysis of a health claims database. Diabetes Obes Metab. 2018;20:2351-2360.