ED Coding and Reimbursement Alert

Plus: Look for changes in how split/shared visits will be viewed.

If you were looking for dramatic changes in this year’s Medicare Physician Fee Schedule Final Rule, the good news is that you won’t have to prep for any earth-shattering changes to how EDs bill and code this year. However, there are some changes that every emergency department should be aware of.

Background: Medicare released the final rule for the 2022 Physician Fee Schedule (PFS) on November 2, 2021. Check out a quick summary from Michael A. Granovsky, MD, CPC, FACEP, president of LogixHealth, a national ED coding and billing company, below.

Physician Fee Schedule Conversion Factor

Like last year, due to CMS’ decision to increase the RVUs for the office and outpatient E/M services in 2021, there is a budget neutrality adjustment, as required by law for 2022 as well. Congress acted to offset most of the budget neutrality cut that was expected go into place in 2021 in the Consolidated Appropriations Act, 2021. Specifically, Congress added back 3.75 percent to the conversion factor.

The published 2022 conversion factor reflects the looming 3.75 percent cut (and a few other adjustments) — and is $33.58, a decrease of $1.31 from the 2021 conversion factor of $34.89. Emergency medicine reimbursement in 2022 will be held flat except for this across-the-board reduction of 3.75 percent.

Like last year, Congress must act before the end of the year to prevent this cut to Medicare payments on January 1, 2022.

ED E/M RVU Changes Remain Basically Stable

CMS did not make changes to the Work RVUs for the ED E/M codes, but there were a few small changes to the Practice Expense and Professional Liability Insurance RVUs at the hundredth decimal place.

Look for E/M Changes

In 2022, CMS is refining several of its current policies for split or shared E/M visits, critical care services, and services furnished by teaching physicians.

Split or shared services: CMS is proposing to continue its current policy allowing billing of certain “split” or “shared” E/M visits by a physician, when the visit is performed in part by both a physician and a non-physician practitioner (NPP), who are in the same group and the physician performs a substantive portion of the visit. CMS is limiting split or shared to E/M codes only, not procedures.

The final rule goes into detail related to split/shared services and different types of visits. Table 26 below from the Final Rule details the possibilities of determining the substantive portion of different visit types.

Critical care: CMS is proposing to allow split (or shared) visit billing in critical care because the agency believes the practice of medicine has evolved toward a more team-based approach to care, and greater integration in the practice of physicians and NPPs, particularly when care is furnished by clinicians in the same group in the facility setting. Since critical care is a time-based service, CMS will require practitioners to document in the medical record the total time that critical care services were provided by each reporting practitioner (not necessarily start and stop times). The provider that provides more than 50 percent of the total time should be the one to report the critical care code.

Critical care policies: CMS clarifies in the rule that if more than one E/M visit is provided on the same day to the same patient by the same physician, or by more than one physician in the same specialty in the same group, “as long as the physician documents that the E/M service was provided prior to the critical care service at a time when the patient did not require critical care, that the service is medically necessary, and that the service is separate and distinct, with no duplicative elements from the critical care service provided later in the day, practitioners may bill for both services. Practitioners must use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the claim when reporting these critical care services,” the agency notes on pages 463-464 of the Physician Final Rule.

Teaching Physicians: CMS clarifies that Medicare will not pay teaching physicians for shared services unless the physician exercises full, personal control over the portion of the case for which the physician is seeking payment.

Stay tuned for more in-depth coverage of the 200 Medicare Physician Fee Schedule in future issues of ED Coding Alert.