ED Coding and Reimbursement Alert

Plus: Payments have been set for the new codes that debut Jan. 1.

When CMS published its 1,250-page Medicare Physician Fee Schedule Final Rule on Nov. 2, the agency announced the myriad new reimbursement values that it will apply to CPT^® codes in 2018. Most notably, CMS has indicated it expects the RUC to review the ED E/M codes in the coming cycle for inclusion in the 2020 Physician fee schedule.

Background: When CMS released its proposed 2018 Fee Schedule last summer, it said, "We have received information suggesting that the work RVUs for emergency department visits may not appropriately reflect the full resources involved in furnishing these services. Specifically, stakeholders have expressed concerns that the work RVUs for these services have been undervalued given the increased acuity of the patient population and the heterogeneity of the sites, such as freestanding and off-campus emergency departments, where emergency department visits are furnished."

Therefore, many EDs took this to mean that changes would be on the horizon for the coming year. However, CMS requires more time to appropriately re-value these services. The final 2018 Fee Schedule notes, "We agree with the majority of commenters that these services may be potentially misvalued given the increased acuity of the patient population and the heterogeneity of the sites where emergency department visits are furnished. As a result, we look forward to reviewing the RUC's recommendations regarding the appropriate valuation of these services for our consideration in future notice and comment rulemaking."

E/M Guidelines May See Updates

Changes that may materialize regarding the E/M codes could go far beyond the ED services and throughout the E/M section of CPT^®, based on indications in the Final Rule.

"We continue to agree with stakeholders that the E/M documentation guidelines should be substantially revised," CMS says in the document. "We believe that a comprehensive reform of E/M documentation guidelines would require a multi-year, collaborative effort among stakeholders. We believe that revised guidelines could both reduce clinical burden and improve documentation in a way that would be more effective in clinical workflows and care coordination. We also think updated E/M guidelines coupled with technological advancements in voice recognition, natural language processing and user-centered design of EHRs could improve documentation for patient care while also meeting requirements for billing and population health management."

In the final rule, CMS vows to work on this issue along with participating stakeholders, but makes no promise of such changes happening next year.

"We believe that a comprehensive reform of E/M documentation guidelines would require a multi-year, collaborative effort among stakeholders," said Michael Granovsky, MD, FACEP, CPC,  President of LogixHealth, a national ED coding and billing company in Bedford, MA. "However, the CMS language does seem to indicate there could be some initial changes coming shortly."

Chronic care management: CMS is also considering updates to the chronic care management (CCM) guidelines after some commenters reported that more than one practitioner should be able to bill these services each month. Many ED physicians take on the role of a patient's primary care practitioners and have argued that they should have the ability to report these codes when applicable. CMS has agreed to "explore ways in which we might better identify and pay for costs incurred by multiple practitioners who coordinate and manage a patient's care within a given month."

Note New Conversion Factor

CMS has set the final 2018 conversion factor at $35.9996, an increase over the current conversion factor, which is $35.8887 or about and 11 cent increase from last year. Remember that to calculate the fee for a Medicare service, you'll multiply the conversion factor by the total relative value units (RVUs). For instance, code 99283 (Emergency department visitfor the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity) currently has a total RVU of 1.75 for 2018, which comes out to a fee of $63.00 when multiplied by the 2018 conversion factor of 35.9996.

New Chest X-Ray Codes Mirror Old Codes' Values

ED coders won't find any earth-shattering values when it comes to the new chest x-ray codes that are set to debut on Jan. 1. Although the code descriptors have changed to reflect the number of views rather than a description of the view itself, such as "frontal and lateral," the work involved is deemed to be the same as in 2017. CMS has assigned the following work RVUs to the new codes:

• 71045 - Radiologic examination, chest; single view: Work RVU is 0.18, which is identical to what the 2017 work RVU has been for 71010 (Radiologic examination, chest; single view, frontal), which will be deleted effective Jan. 1.
• 71046 - Radiologic examination, chest; 2 views: Work RVU is 0.22, which matches the same RVU as soon-to-be deleted code 71020 (Radiologic examination, chest, 2 views, frontal and lateral)
• 71047 - Radiologic examination, chest; 3 views: Work RVU is 0.27 (no matching code exists for 2017)
• 71048 - Radiologic examination, chest; 4 or more views: Work RVU is 0.31, which matches the RVUs of 71030 (Radiologic examination, chest, complete, minimum of 4 views), which will be deleted on Jan. 1.

Resource: To read more about the Final Rule, see CMS' Fact Sheet at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html.