Few phrases can make a physician’s eyes glaze over faster than “Medicare Physician Fee Schedule proposed rule.” Yet evaluation and management policy is not merely bureaucratic wallpaper. E&M rules influence what clinicians document, how practices are paid, which services remain financially sustainable, and how much of a medical visit is spent looking at the patient rather than wrestling with an electronic health record.
The Centers for Medicare & Medicaid Services once proposed a sweeping overhaul of office and outpatient E&M services. Its goal was appealing: reduce unnecessary documentation, simplify coding, and return time to patient care. Unfortunately, CMS attached that sensible reform to a payment model that risked treating a routine follow-up and an intensely complex encounter as financial twins wearing different name tags.
The proposal therefore deserved neither automatic rejection nor enthusiastic applause. The better response wasand remainsto preserve the documentation reforms while correcting the payment policies that undervalue cognitive work, complex patients, and separately identifiable services.
What Are E&M Services, and Why Do They Matter?
Evaluation and management services cover the professional work involved in assessing patients, reviewing information, making diagnoses, estimating risk, developing treatment plans, coordinating care, and discussing those plans with patients or caregivers. In office settings, these services have traditionally been reported through CPT codes representing different levels of complexity.
Before the major revisions implemented in 2021, code selection often depended heavily on detailed requirements for history, examination, and medical decision-making. The 1995 and 1997 documentation guidelines encouraged clinicians to count review-of-systems elements, examination bullets, and other components that did not always reflect the encounter’s true clinical difficulty.
This produced a familiar spectacle: a physician might perform sophisticated diagnostic reasoning in 20 minutes, then spend another 15 minutes clicking boxes to prove that sophisticated diagnostic reasoning had occurred. Medicine became the only profession where doing the work was sometimes easier than documenting the work.
What CMS Originally Proposed
In its proposed 2019 Medicare Physician Fee Schedule rule, CMS presented a package of office and outpatient E&M changes intended to support its “Patients Over Paperwork” initiative. The package contained several distinct ideas, and separating them is essential.
More Flexible Documentation
CMS proposed allowing clinicians to choose among several methods for supporting an office visit. Depending on the encounter, a practitioner could rely on medical decision-making, time, or the existing documentation framework.
For established patients, clinicians would not have to reproduce an entire history when the relevant information was already present in the record. They could document what had changed, confirm pertinent information that remained unchanged, and indicate that previous material had been reviewed.
CMS also proposed allowing physicians and other qualified professionals to review and verify information entered by patients or ancillary staff instead of typing it again. This was not an invitation to stop taking histories. It was an invitation to stop pretending that manually re-entering the same history made it more medically authentic.
A Single Blended Payment for Levels 2 Through 5
The controversial part was the proposed payment structure. CMS suggested paying one blended rate for office and outpatient E&M levels 2 through 5, with separate rates for new and established patients.
Using the payment estimates published with the proposal, established-patient visits at levels 2 through 5 would generally have been paid approximately $93. New-patient visits at those levels would generally have been paid approximately $135. Under that model, lower-level services could receive more, while many level 4 and level 5 encounters would receive less.
| Visit Type | Original Structure | Proposed Blended Structure |
|---|---|---|
| Established patient, levels 2–5 | Payment increased with visit level | Approximately $93 for each level |
| New patient, levels 2–5 | Payment increased with visit level | Approximately $135 for each level |
| Documentation | History, exam, and MDM requirements | Greater flexibility and a lower minimum standard |
The proposal would have simplified payment, but simplicity is not automatically accuracy. A kitchen timer is simple too, but nobody uses one to measure blood pressure.
Add-On Codes and a Same-Day Payment Adjustment
CMS attempted to compensate for variation through add-on payments. The agency proposed modest additional amounts for primary care, certain nonprocedural specialty services, and prolonged encounters.
It also proposed reducing payment when a separately reportable E&M visit occurred on the same day as a procedure. That provision generated substantial concern because an E&M service billed with modifier 25 is supposed to represent work that is significant, separately identifiable, and above the routine assessment included in the procedure.
A patient may arrive for a skin lesion and also present with a new medication reaction. Another may undergo a joint injection only after a thorough evaluation of worsening pain, new weakness, and alternative treatment options. The procedure does not magically erase the cognitive work that preceded it.
What CMS Got Right
The strongest part of the proposal was its recognition that clinical notes should support patient care rather than serve as elaborate scavenger hunts for billing elements.
Less Copying, More Updating
Allowing a clinician to review existing information and document meaningful changes is more clinically useful than reproducing a complete history at every visit. A medication list should be reconciled, not ceremonially retyped. A family history should be updated when appropriate, not copied into eternity like an ancient billing incantation.
Medical Decision-Making as the Center of the Visit
For many encounters, medical decision-making is the best representation of professional work. It considers the problems addressed, the information reviewed and analyzed, and the risk associated with testing or treatment.
A concise note can document high-value care when it clearly explains the clinician’s assessment, uncertainty, risk analysis, and plan. By contrast, a six-page note assembled from templates may reveal surprisingly little beyond the EHR’s enthusiasm for duplication.
Recognition of Work Performed Outside the Exam Room
Time-based coding reforms also acknowledged that patient care may include reviewing outside records, analyzing test results, communicating with other professionals, documenting the encounter, and coordinating treatment. Much of this work occurs before or after the face-to-face conversation but is still part of the service.
That recognition was particularly important for primary care, oncology, neurology, geriatrics, and other fields in which complex care routinely spills beyond the scheduled appointment.
Why the Blended Payment Proposal Was Problematic
Not All Visits Consume the Same Resources
A stable blood-pressure follow-up is not equivalent to evaluating an older adult with heart failure, chronic kidney disease, diabetes, dizziness, ten medications, abnormal laboratory results, and a worried daughter carrying a three-page list of questions.
Both encounters matter. Both deserve appropriate documentation. They do not, however, require identical physician time, diagnostic reasoning, risk management, or coordination.
A single payment rate could reward practices with a high proportion of lower-complexity visits while penalizing physicians caring for patients with multiple chronic illnesses, diagnostic uncertainty, treatment complications, or substantial social barriers.
Complex Specialties Faced Disproportionate Risk
Neurologists, oncologists, rheumatologists, and other cognitive specialists frequently manage patients whose visits qualify for higher-level E&M services. Their work may include reviewing extensive imaging, interpreting laboratory trends, comparing treatment pathways, discussing serious risks, and coordinating care across multiple teams.
Flattening payment could have made these services less sustainable, particularly in independent practices. When reimbursement falls below the resources required to provide care, practices do not simply absorb the difference forever. They reduce appointment availability, avoid certain services, seek hospital acquisition, or close.
The ultimate policy question is therefore not merely, “Will doctors receive less?” It is, “Will patients still be able to find a doctor willing and able to provide this care?”
Add-On Codes Could Not Fully Repair a Blunt Base Rate
Add-on codes sounded promising, but the proposed amounts were modest and their application could create fresh coding uncertainty. Practices would need to determine which visits qualified, build new billing workflows, train staff, update software, and prepare for payer interpretations.
A payment system is not truly simple when it replaces five familiar visit levels with one base rate, several add-ons, prolonged-service rules, modifier questions, and a new compliance seminar featuring 84 slides and lukewarm coffee.
The Same-Day Reduction Threatened Legitimate Care
Procedural visits often contain two components: deciding whether a procedure is appropriate and performing it. The evaluation may uncover contraindications, identify a different diagnosis, or lead the clinician to recommend another treatment entirely.
An automatic payment reduction assumes overlap even when the documentation supports a distinct service. It may also encourage patients to return on a second day so the practice can receive full paymenthardly an administrative victory for a patient who must arrange transportation, miss work, or travel from a rural community.
What Happened After the Proposal?
CMS received extensive feedback and did not implement the original package exactly as proposed. The 2019 final rule introduced immediate documentation relief, including allowing clinicians to review and verify information entered by patients or staff and to focus established-patient documentation on relevant changes.
CMS initially delayed and modified the blended-payment plan. Level 5 visits were separated from levels 2 through 4, and the agency abandoned the proposed same-day E&M payment reduction. Continued work among CMS, the American Medical Association, specialty societies, and other stakeholders ultimately produced a different framework for 2021.
Under the office and outpatient E&M revisions effective January 1, 2021, clinicians could select most visit levels based on either medical decision-making or total time on the date of service. History and examination remained medically important but no longer determined the code level. Code 99201 was deleted, while the remaining office visit levels retained distinct definitions and valuations.
This outcome demonstrated that regulatory feedback can work. CMS preserved much of the documentation-reduction “baby” while draining away a substantial portion of the problematic payment “bath water.”
Did the Reforms Actually Reduce Documentation Burden?
The results have been encouraging but incomplete. Many physicians report spending less effort documenting lengthy reviews of systems and examinations that do not contribute meaningfully to care. An American Academy of Family Physicians survey found that roughly half of responding members experienced some reduction in documentation burden.
However, research using EHR activity data has found that average documentation-time reductions were often small. That is not surprising. Changing a Medicare rule does not automatically remove old templates, employer policies, prior-authorization demands, quality-reporting requirements, malpractice concerns, or the habits clinicians developed during years of audit anxiety.
In other words, CMS loosened the handcuffs, but some organizations continued wearing them because nobody had updated the employee manual.
Practices receive the greatest benefit when policy reform is paired with template redesign, coder education, consistent payer rules, team-based documentation, and permission from compliance leaders to stop collecting obsolete information.
The Issue Is Relevant Again
The same-day payment debate has not disappeared. In its proposed Medicare Physician Fee Schedule for calendar year 2027, CMS again proposed reducing payment when a separately identifiable office or outpatient E&M service is provided on the same day as a procedure with a 0-, 10-, or 90-day global period.
Under the new proposal, the most expensive service would generally be paid in full, while additional qualifying E&M services or procedures would be paid at 50%. CMS explicitly connected this policy to the proposal consideredbut not finalizedfor 2019.
The revival reinforces the original lesson: administrative efficiency should not be achieved by applying an automatic discount to clinically distinct work. CMS should evaluate actual overlap, patient convenience, procedural workflow, modifier 25 requirements, and specialty-specific effects before finalizing a broad reduction.
A Better Framework for Future CMS E&M Changes
Preserve Clinically Meaningful Documentation
Require enough information to explain the patient’s condition, the clinician’s reasoning, the risks considered, and the treatment plan. Eliminate requirements that encourage irrelevant text solely to satisfy a coding formula.
Maintain Payment Differences for Meaningful Complexity
Visit levels should reflect differences in physician work, time, risk, and practice resources. Simplification should make those distinctions easier to support, not pretend they do not exist.
Pay Separately Identifiable Work Fairly
When a procedure and an E&M service are genuinely distinct, both should be paid appropriately. CMS can strengthen auditing and education without assuming that every same-day combination contains duplication.
Test Policies Before Applying Them Nationally
CMS should model specialty-level and patient-level effects, pilot major changes, publish the findings, and revise proposals before they disrupt access. A mathematically budget-neutral policy can still be clinically lopsided.
Measure Patient Outcomes, Not Just Reduced Spending
A proposal should not be declared successful merely because claims cost less. CMS should examine appointment availability, delayed care, clinician consolidation, administrative time, patient travel, and access for people with complex conditions.
Practice-Floor Experiences: Composite Scenarios
The following experiences are composite examples based on common medical-practice workflows. They do not describe identifiable patients or claim to be firsthand personal accounts.
The Primary Care Visit That Refused to Fit in a Box
A family physician begins the morning expecting a routine diabetes follow-up. The patient arrives with rising glucose levels, new ankle swelling, several missed doses of medication, and a discharge summary from an emergency department visit that never reached the clinic.
The physician reviews laboratory results, reconciles eight prescriptions, evaluates possible heart failure, changes the diabetes plan, orders testing, contacts a cardiologist, and discusses warning signs with the patient’s spouse. The physical examination takes only a few minutes. The reasoning and coordination consume most of the visit.
Under the old documentation rules, the physician might have felt compelled to record an extensive review of systems and examination to support a higher code. Under the revised approach, the note can focus on the problems addressed, data reviewed, treatment risk, and plan. That is a real improvement.
Under a blended payment model, however, the encounter might receive the same base payment as a much simpler visit. The paperwork burden falls, but the economic mismatch remains. The practice saves a few clicks while losing the resources needed to reserve longer appointments for complex patients.
The Dermatology Visit With Two Legitimate Services
A patient schedules an appointment for a changing skin lesion. During the visit, the dermatologist also evaluates a widespread rash that began after a new medication. The lesion is biopsied, but the rash requires a separate history, examination, differential diagnosis, medication review, treatment plan, and communication with the prescribing physician.
The biopsy includes some routine assessment, but it does not include the work of managing a suspected drug eruption. Billing an E&M service with modifier 25 may therefore be appropriate when the record clearly supports the distinction.
A blanket 50% reduction would discount one service despite the separate work. The clinic could ask the patient to return later for the rash, but that creates another copayment, another trip, another appointment, and another opportunity for the condition to worsen. The accounting becomes tidier while the patient’s life becomes messier.
The Oncology Visit Where Conversation Is the Treatment
An oncologist meets with a patient whose imaging shows disease progression. No procedure is performed. The physician reviews scans, pathology, laboratory results, previous therapies, possible clinical trials, and the risks of several treatment options. The patient and family need time to understand what the findings mean.
The visible output may be a medication order and a concise note. The invisible work includes years of specialized training, probabilistic reasoning, emotional communication, and coordination with other professionals.
A payment model that compresses this encounter into the same category as a straightforward follow-up sends the wrong signal about cognitive care. It implies that thinking has little cost because it does not arrive in a sterile package with a procedure code attached.
The Practice Manager’s Post-Reform Reality
After the 2021 changes, a multispecialty practice trains clinicians to code based on medical decision-making or total time. Initially, note length barely changes. The EHR still loads old templates, physicians remain worried about audits, and commercial insurers offer inconsistent instructions.
The practice then removes unnecessary review-of-systems fields, develops short examples for common visits, audits for clinical clarity rather than note weight, and teaches physicians how to document independent interpretation, treatment risk, and total time correctly.
Within several months, notes become shorter and easier to read. Physicians still document complex encounters thoroughly, but they stop recording irrelevant normal findings just to reach a billing threshold. The reform finally produces its intended benefitnot because the regulation worked alone, but because the organization redesigned its workflow around it.
Conclusion
The proposed CMS E&M changes contained a genuinely valuable idea: physicians should document clinically meaningful care without performing ritualistic box-checking. That principle was worth preserving and ultimately helped shape the more practical office-visit rules implemented in 2021.
The original blended payments and same-day service reductions were different matters. They risked undervaluing complex cognitive care, creating specialty-specific losses, and encouraging patients to make unnecessary return visits. Current proposals that revisit automatic same-day reductions deserve the same careful scrutiny.
The best E&M reform is not the one with the fewest codes or the cheapest claims. It is the one that makes documentation clearer, payment more accurate, and care easier to access. CMS should keep the useful reforms, repair the blunt payment policies, and resist mistaking administrative neatness for clinical wisdom.
Research grounding: CMS CY 2019 proposed and final Physician Fee Schedule materials; CMS CY 2027 proposed rule; AMA CPT E/M guidance; AAFP and ACP analyses; peer-reviewed studies of documentation burden.
