Reimbursement and Coding Updates for 2013

ACEP News
January 2013
 

By Michael A. Granovsky, M.D.  

The Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician Fee Schedule Final Rule Nov. 1, 2012, which addresses changes to the physician fee schedule as well as other important Medicare part B payment policies. The rule is effective beginning Jan. 1, 2013 and is published in the Nov. 25, 2012 Federal Register.

The 2013 Conversion Factor
We finished 2012 with a Medicare Conversion factor (the Medicare payment per RVU) of $34.0376. The much loathed SGR (Sustainable Growth Rate) formula remains on the books and with the expiration of the latest congressional “patch” on December 31, 2012 the 2013 Final Rule published a conversion factor of $25.0008 representing a 26.5% cut to physician payments. Each year, after significant and organized physician pleading Congress has staved off our draconian cuts since 2003 with a variety of short term patches. This year a lame duck Congress addressed the SGR issue against a backdrop of potential tax and entitlement reforms.  Congress provided an SGR patch through December 31st and elected to maintain the conversion factor at nearly identical levels to 2012, though they left Medicare vulnerable to the 2% across the board cuts scheduled to take place in March, as mandated by the Sequestration.

 

Calculation of the CY 2013 PFS Conversion Factor

Conversion Factor in effect in CY 2012                                           $34.0376

CY 2012 ConversionFactor had statutory increases not applied    $24.7612

CY 2013 Medicare Economic Index                                                0.8 percent (1.008)

CY 2013 Update Adjustment Factor                                                0.6 percent (1.006)

CY 2013 RVU BN Adjustment                                                        -0.1 percent (0.99932)

CY 2013 Conversion Factor                                                        $25.0008  

Percent Change from CY 12 to CY 13                                       -26.5%  

American Taxpayer and Relief Act                                            $34.0230

 

GPCI Artificial Floor Provision is Set to Expire  

Alaska and the Medicare designated “frontier states” (MT, ND, SD, NV, and WY) continue with permanent minimum work Geographic Practice Cost Index (GPCI) adjustments to their Medicare rates. Alaska has a GPCI of 1.5 and the frontier states are assigned a GPCI of 1.0. Outside of these 6 states the artificial GPCI floor of 1.0 is set to expire which would impact many rural areas, resulting in decreased Medicare payments. Historically, the GPCI floor provision has been extended as part of the annual SGR patch legislation.

 

ED E/M RVUs Are Basically Unchanged for 2013  

According to the CMS, specialty specific impact analysis Emergency Medicine will not see a significant decrease in our overall RVU values. As published in the 2013 rule Emergency Medicine will experience a 0% update to our overall RVU values in 2013. Essentially, our RVUs are stable and relatively unchanged. This is independent of any change to the conversion factor. The RVUs for our major reimbursement drivers, the E/M codes have only second decimal point adjustments predominantly due to small changes in Practice Expense. Of note, the work RVUs have not changed for 2013 and remain stable at 2012 levels.

Emergency E/M RVUs in the 2013 Medicare Final Rule

 

   

Code

Description

2012
Work RVUs

2013
Work RVUs

2012 Facility
PE RVUs

2013 Facility
PE RVUs

2012
Total RVUs

2013
Total RVUs

99281

ED visit, level 1

0.45

0.45

0.12

0.12

0.60

0.60

99282

ED visit, level 2

0.88

0.88

0.23

0.23

1.18

1.18

99283

ED visit, level 3

1.34

1.34

0.33

0.32

1.77

1.76

99284

ED visit, level 4

2.56

2.56

0.59

0.58

3.37

3.36

99285

ED visit, level 5

3.80

3.80

0.84

0.83

4.94

4.93

99291

Critical Care

4.50

4.50

1.54

1.56

6.38

6.40


Other services frequently provided by emergency physicians have also had their RVUs adjusted by the 2013 rule. For 2013, Critical Care is essentially unchanged and Observation will see small increases.

 

Critical Care E/M RVUs in the 2013 Medicare Final Rule  

 

CPT Code

 

Description

2012
Work RVU

2013
Work RVU

2012 Facility
PE RVUs

2013 Facility
PE RVUs

2012 Total

RVUs

2013 Total

RVUs

99291

Critical Care

1st hour

4.50

4.50

1.54

1.56

6.38

6.40

99292

Critical Care

add'l 30 min

2.25

2.25

0.77

0.79

3.20

3.22

 

 

 

Observation E/M RVUs in the 2013 Medicare Final Rule

CPT Code

Description

2012
Work RVU

2013
Work RVU

2012
Facility PE

RVUs

2013

 Facility PE 
RVUs

2012
Total RVUs

2013 Total

RVUs

99217

Observation

Care Discharge

1.28

1.28

0.70

0.72

2.06

2.08

99218

Initial observation

care

1.92

1.92

0.73

0.80

2.77

2.84

99219

Initial observation

care

2.60

2.60

1.04

1.10

3.81

3.87

99220

Initial observation

care

3.56

3.56

1.43

1.50

5.23

5.30

99224

Subseq. observation

care

0.76

0.76

0.32

0.32

1.14

1.14

99225

Subseq. observation

care

1.39

1.39

0.60

0.60

2.06

2.06

99226

Subseq. observation

care

2.00

2.00

0.85

0.86

2.96

2.97

99234

Observ/hosp

same date

2.56

2.56

1.08

1.08

3.86

3.86

99235

Observ/hosp

same date

3.24

3.24

1.38

1.37

4.84

4.83

99236

Observ/hosp

same date

4.20

4.20

1.74

1.75

6.23

6.24

 

Primary Care Bonus and Medicare Rates for Medicaid Patients

On November 1, 2012, CMS released the final regulations which implement Section 1202 of the Affordable Care Act. This specific section increases Medicaid payments for specified primary care services to Medicare levels for certain primary care physicians for the years 2013 and 2014. The rationale for this increase was to entice certain primary care providers into accepting new Medicaid patients when the states expanded their Medicaid roles to anyone up to 133% of the poverty level. Historically, the Massachusetts experience related to insurance expansion demonstrated that insurance does not equate to access to medical care. Increasing Medicaid physician fees in many states, to that of the Federal Medicare program would enhance physician reimbursement by potentially 30 percent. CMS has stated that it did not intend to allow anyone Board Certified in Emergency Medicine, to participate in the program and the increased reimbursement will generally be for Family Physicians, General Internal Medicine and Pediatrics. 


Regulatory Update: The PQRS (Physician Quality Reporting System) continues with a 0.5% bonus for successful reporting in 2013 which will continue through 2014 and transition to a -1.5% penalty phase beginning in 2015. The CMS Physician Compare website is now live and being populated with basic physician identifying information as well as whether the physician successfully reported PQRS in 2010. Successful PQRS reporting for 2013 will require reporting on 50% of eligible cases for 3 measures. Be aware (see ACEP news XXX) that several important ED measures have been retired for 2013 including pneumonia assessment of oxygen saturation and pneumonia assessment of mental status .

Transitional Care Management (TCM) and Chronic Complex Care Coordination (CCCC) Code Use by EPs

New codes have been created to report services provided during the first 29 days following an admission (Transitional Care Management 99495-99496) as well as the coordination of care for those patients with complex medical issues involving multiple comorbidities (Complex Coordination of Care 99487-99489). These so called “quarterback codes” have been established to promote better coordination of care typically by primary care physicians and certain specialists (such as Oncology) that provide long term longitudinal care for patients. ED physicians will not likely satisfy the requirements for reporting these services for the following reasons:

CPT uses the phrase “established patient” with the idea being the provider who is discharging the patient also provides the services required by the TCM code. The listed set of requirements include items emergency physicians do not typically have the infrastructure to provide such as communication with home health agencies, assessment and support for the treatment regimen, and assistance with scheduling

Only a single provider may report these once a month so the emergency physician would have to coordinate with the rest of the medical staff if reporting TCM services. There is a CMS presumption that discharging physicians inform the beneficiaries that they should receive TCM services from their doctor or other practitioner after their discharge, and that Medicare will pay for those services.”

The allowance of the ED 9928x codes, though not expressly stated, is probably to allow the primary care doctor or specialist who provides ED care during their TCM period to also bill for their ED services. Recall, Medicare eliminated the consult codes so non ED docs had been directed to bill 9928x for services they rendered in the ED. Unfortunately, the funding for these services comes from the general Medicare pool of monies utilizing so called “budget neutrality” which will drive down the ultimate Conversion factor for Emergency Physicians.

CPT Coding Changes for 2013 
Beginning in 2013 there are several CPT code changes of interest to emergency physicians. Taken from the 2013 CPT book, here are the highlights you will want to incorporate into your coding starting January 1st. There is new language for 2013 in each of the E/M codes, which eliminates the word “provider” and replaces it with “qualified healthcare professional” to be consistent with the expanded use of PAs and Nurse practitioners as well as other medical personnel. Here is what it looks like for the ED E/M codes using 99283 as an example. 

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.

Counseling and/or coordination of care with other physicians, qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the presenting problem(s) are of moderate severity. 
 

Changes to Observation Codes
Previously CPT had not published typical times for the Observation codes 99234-99236. For 2013 CPT has added typical times to the definitions. These represent the amount of time a physician spends in caring for the patient and should not be confused with the CMS regulation for this code set which requires the patient to be in Observation status for a minimum of 8 hours.

The observation same day admit and discharge codes have been updated for 2013 with typical times listed in the code descriptors.

99234 Observation or inpatient hospital care, for the evaluation and treatment of a patient including admission and discharge on the same date, which requires these 3 key components:

A detailed or comprehensive history;

A detailed or comprehensive examination;

Medical decision making that is straightforward or of low complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually the problem(s) requiring admission are of low severity. Typically 40 minutes are spent at the bedside and on the patient’s hospital floor or unit.

Similar typical times now appear for 99235 and 99236

99235 …Usually the problem(s) requiring admission are of moderate severity. Typically 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99236 …Usually the problem(s) requiring admission are of high severity. Typically 55 minutes are spent at the bedside and on the patient’s hospital floor or unit.

 

Significant Revisions to the Chest Drainage Procedure Codes

In CPT® 2013 we see a reorganization of the codes used to describe chest drainage procedures with some prior codes being deleted and replaced with new codes.

Codes 32420, 32421, and 32422 have been deleted. 

32420 Pneumocentesis, puncture of lung for aspiration

32421 Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent

32422 Thoracentesis, with insertion of tube, includes water seal (e.g., for pneumothorax), when performed (separate procedure) 

To report those services you should now use one of the four new codes thoracentesis codes

32554 Thoracentesis, needle or catheter; without imaging guidance

32555 with imaging guidance

32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance

32557 with imaging guidance 

 

There is also an increas in the number of views required for cervical spine x-rays.

72040 Radiologic examination, spine, cervical; 3 views or less 4 or 5 views

72052 6 or more views 

 

We see the “other qualified healthcare professional” language appearing in the radiology section as well as the E/M section. For example:

76000 Fluoroscopy (separate procedure), up to one hour physician or other qualified health care professional time Fluoroscopy (separate procedure), up to 1 hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy)

 

Just in Time for Flu Season, We Have Some Changes in the Influenza Codes

There is a new code for influenza vaccine:

FDA approval pending90653 Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use

 
You will recall that he lightening symbolFDA approval pending in CPT® means FDA approval pending

Other influenza codes 90655-90660 influenza have been revised by adding the word “trivalent” in the code descriptor. For example:

90655 Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use,

And another new code for influenza vaccine appears at the end of that code sequence:

90672 Influenza virus vaccine, quadrivalent, live, for intranasal use

 

ICD 10 Update:  The ICD 10 implementation date has been pushed back to October 1, 2014.  As such, the current diagnosis code set has been frozen with new diagnosis codes only allowed for key and novel diseases until after ICD 10 is live.

Other Resources
Resources for these and other topics can be found on the reimbursement section of the ACEP website. The ACEP Coding and Nomenclature Advisory Committee, the ACEP Reimbursement Committee, and ACEP Reimbursement Department staff members David McKenzie, CAE, and Amy Wynn, CPC are also available to field your questions at 800 708-1822, ext. 3232. Finally, ACEP offers well-attended and highly recommended coding and reimbursement educational conferences annually with the next offering February 23rd- 7th in San Diego (R&C Conference)

About the Author: Dr. Granovsky is the President of LogixHealth, an ED Coding and Billing Company and currently serves as the Chair of ACEP’s Coding and Nomenclature Advisory Committee. Mr. McKenzie is the Director of the ACEP Reimbursement Department and serves as Staff Liaison for the AMA RUC and CPT processes.

 
 
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