ED Coding and Reimbursement Alert

Plus: What’s the proposed conversion factor for 2019?

The proposed physician fee schedule includes much more information beyond the suggested E/M code changes, including potential updates regarding the quality measures. The proposal suggests adjustments that provide much-needed changes to Measures 415 and 416, which EDs use.

Here’s the update: These measures refer to patients that get head CTs following minor blunt head trauma. “In previous versions of the measure, the head trauma had to be within 24 hours and you had to document a Glasgow Coma Scale (GCS) score of 15, which is a wide-awake patient, in order for that measure to apply,” said Michael Granovsky, MD, FACEP, CPC,  President of LogixHealth, a national ED coding and billing company based in Bedford Massachusetts.

Most EHRs, however, don’t actually have an easy mechanism for the physician to document GCS, and in addition, when the GCS is 15 and the patient is wide awake, the physician wouldn’t be inclined to document that – so the measure is now more useable by removing the requirement of the GCS documentation and the record requirement that the head trauma occurred within the 24 hours. The current measure definitions are as follows:

• Measure 415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older: Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.
• Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years: Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.

Get to Know How Pay Could Change in 2019

In addition to the Fee Schedule proposals that could impact E/M coding and quality measures, CMS also made more suggestions in the document that could impact EDs nationwide. Across the board, the Medicare Physician Fee Schedule (MPFS) proposals keep the agency’s “Patients Over Paperwork” pledge on the federal healthcare delivery plate. Every aspect of the proposed rule promotes CMS’s heightened focus on utilizing health IT to enhance care and cut costs while decreasing clinicians’ workloads.

Here are a few of the highlights from the 1,000-page-plus CY 2019 MPFS proposed rule:

• Conversion factor: Lower than last year’s 10-cent bump, the conversion factor proposal is nothing to write home about at a 6-cent increase for inflation and slated to go from $35.99 to $36.05.
• QPP. The MPFS proposals include transition updates, cost and quality scoring changes, threshold guidance, small practice bonus downgrades, and several tech-friendly policies that bring Promoting Interoperability (PI) to center of MIPS.
• Telehealth. Two more codes for telehealth — HCPCS codes G0513 and G0514 (Prolonged preventive service[s]) — as well as 2018 Bipartisan Budget Act telehealth requirements for end-stage renal disease.
• Virtual care. Payment increases for the use of audio and visual communication that “leverage technologies.”
• Medicare Advantage. MIPS requirements would be waived for Medicare Advantage providers interested in participating in the QPP. The program will be called the “Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration” and is for clinicians whose “arrangements are similar to Advanced APMs,” explains the fact sheet.

Based on all of the proposed changes, CMS projects that independent laboratories lead the pack of specialists who will prosper in 2019 if the proposed fee schedule is finalized, with an estimated combined increase of four percent, while rheumatologists, hematologists/oncologists, and diagnostic testing facilities look to see the biggest declines at minus four percent. ED physicians aren’t facing either extreme, as the fee schedule indicates that under the proposal, emergency medicine specialists would see no payment change.