EM Coding Alert

But RVUs, CCM, and E/M guideline changes still on hold.

Have you noticed a small rise in your revenues this year? If you have, it's because the Centers for Medicare & Medicaid Services (CMS) increased the conversion factor by 11 cents in the 2018 Fee Schedule.

But, as we briefly reported last month, guidelines for reporting evaluation and management (E/M) services and guidelines for chronic care management (CCM) don't look like changing any time soon.

And CMS is, unfortunately, still on the fence when it comes to increasing relative value units (RVUs), even though it admits that E/M services, especially those provided in emergency departments (EDs) across the country, are still undervalued.

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 guidelineswould 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 an 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 visit for 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.