ED Coding and Reimbursement Alert

Read on to find out why and what other changes are proposed

The proposed rule for the 2013 Medicare Physician fee schedule, released July 6, includes three key items of special interest to ED coders, namely a new code for coordination and transition of care following a visit to an inpatient facility, expansion of the prepayment review audits, and changes to ED specific PQRS measures.

As in recent years, CMS is planning for an SGR mandated cut in physician payments of roughly 27.5percent, unless Congress steps in again to repeal the SGR formula or extend another patch to delay the projected severe cuts. Otherwise, the ED related codes should maintain their current RVUs with the specialty of emergency medicine estimated to take about a one percent cut in payments due to issues related to practice expense and additional procedural bundling, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, MA.

Review This New Code For Care Coordination

For 2012 CMS is proposing to create a new HCPCS G code to describe non-face-to face services related to transitional care management in the 30 days following discharge to the community from an inpatient hospital stay, skilled nursing facility (SNF) stay, and specified outpatient services.

Although Medicare traditionally pays for care management services in conjunction with a face-to-face visit, the proposed new procedure code would establish a separate payment for care management services for the beneficiary that occur outside a face-to-face encounter with the community physician. The proposed code would include:

• Assuming responsibility for the beneficiary's care without a gap
• Establishing or adjusting a plan of care to reflect required and indicated elements
• Communication (direct contact, telephone, electronic) with the beneficiary and/or caregiver
• Communication with other health care professionals who will (re)assume care of the beneficiary, education of patient, family, guardian, and/or caregiver
• Assessment of the need for and assistance in coordinating follow up visits with health care providers and other necessary services in the community
• Establishment or reestablishment of needed community resources
• Assistance in scheduling any required follow-up with community providers and services

CPT® has a work group investigating similar code language. Care coordination will be increasingly important as CMS implements the Readmission Reduction Program in October 2012, Granovsky explains.

CMS is also proposing to remove a limitation placed on contractors to continue complex prepayment medical review if a provider or supplier has failed to reduce its individual error rate. This could result in a significant expansion of the current prepayment reviews, Granovsky adds.

Nix Most Frequently Reported ED PQRS Measures

CMS proposes to retain the 12-month calendar year reporting period for the PQRS program in 2013 and beyond. The incentive payment for 2013 will remain 0.5 percent. The 2013 reporting period data will be used to determine both the 2013 incentive payment (0.5 percent) and the 2015 payment adjustment (-1.5 percent).

Successful reporting requirements for the program are proposed to remain as they were in 2012, requiring that participants report a minimum of three individual measures or group measure via claims based reporting on 50% or more of all eligible Medicare patients, or report a minimum of three individual measures or 1 group measure via registry reporting on 80% or more of all eligible Medicare patients, says Granovsky.

In the Proposed Rule, CMS indicates its proposed plan to potentially eliminate the following measures:

• 57- Community-Acquired Pneumonia (CAP): Assessment of Oxygen saturation
• 58- Community-Acquired Pneumonia (CAP): Assessment of Mental Status
• 92- Acute Otitis Externa (AOE): Pain Assessment
• 253- Pregnancy Test for Female Abdominal Pain Patients

Big dent: Losing measures 57 and 58 will impact a significant percentage of those groups who are successfully participating in PQRS. The above pneumonia measures are widely used by emergency physicians to satisfy the PQRS reporting requirement, warns Granovsky. However, two of the pneumonia measures 56 (Community-Acquired Pneumonia [CAP]: Vital Signs) and 59 (Community-Acquired Pneumonia [CAP]: Empiric Antibiotic) do remain, as well as Measure 28 (Aspirin at Arrival for Acute Myocardial Infarction) and Measure 54 (12 lead ECG Performed for Non Traumatic Chest Pain) and Measure 55 (EKG for syncope) the other typically utilized ED PQRS measures will remain in use.

There had been a stand-alone pneumonia group measure which is proposed to be eliminated. This group measure combined the four individual pneumonia measures (56, 57, 58 and 59) into a single group and was not being frequently utilized as a reporting mechanism.

Check Out Additional Telehealth Uses

CMS also proposes an expansion of telehealth services to include an annual alcohol misuse screening, brief behavioral counseling for alcohol misuse, annual face-to-face intensive behavioral therapy for cardiovascular disease, annual depression screening, behavioral counseling for obesity, and semi-annual high intensity behavioral counseling to prevent sexually transmitted infections, says Granovsky