Reimbursement and Coding Updated for 2011
By Michael A. Granovsky, M.D.
January 7, 2011
The Centers for Medicare and Medicaid Services (CMS) issued the Medicare Physician Fee Schedule Final Rule Nov. 2, 2010, which implements aspects of the Patient Protection and Affordable Care Act of 2010, as well as the Health Care and Education Reconciliation Act.
Additionally, the 2011 Medicare Physician Fee Schedule final rule updates payment rates for physician services beginning with dates of service Jan. 1, 2011 and contains a significant decrease in physician rates with a Medicare Conversion Factor (Medicare’s Reimbursement per RVU) of $25.5217, representing a 30% cut to current rates.
Emergency physicians entered 2010 facing a 21.6% decrease to the conversion factor. What followed were a series of small Congressional “patches” that forestalled the severe cuts for only several months at a time creating great physician uncertainty. On Dec. 19, 2009, the congress passed, via the Department of Defense Appropriations Act, a 2 month freeze to the Medicare physician fee schedule effective from Jan. 1, 2010 through Feb. 28, 2010, thus preserving physician reimbursement at current levels and saving us from the 21% cut.
Two additional patches (including the March 2 Temporary Extension Act of 2010 and the April 15 2010 Continuing Extension Act) extended relief from the impending significant reduction through May 31, 2010. Emergency physicians then received a small increase through the June 25 Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act, which provided for a 2.2 % increase to the conversion factor effective for dates of service June 1, 2010 through Nov. 30, 2010; the conversion factor for services furnished during this time period was $36.8729.
On Dec. 15, President Obama signed a 1-year pay fix into law. The law will eliminate the scheduled deep fee-schedule curt and instead deep Medicare physician fees at their current rate throughout 2011.
Several other factors will impact emergency physician reimbursement for 2011. Adjustments to the Medicare Economic Index (MEI) related to changing the base year from 2000 to 2006 have been updated to reflect changes in prices of goods and services physicians purchase to run their practices and will have a negative impact on emergency medicine of roughly 3 %. Practice expense values for 2011 represent year two of a four year transition to the new practice expense survey data, which will contribute a 0.5% increase to emergency department reimbursement.
Additionally, the timeline for submitting claims to CMS has been significantly shortened. CMS has reduced the maximum time for claim submission from 27 months to 12 months, as mandated by the Patient Protection Act.
Change in Global Surgical Package Impacts ED Procedures
The RVUs for procedures are determined based on a methodology that takes into consideration pre-service, intra-service and post-service work. Certain emergency department procedures have been revalued by the CMS with a decrease in the global surgical package from the typical 10 days for most ED minor procedures to 0 days, resulting in a significant decrease in the ultimate RVU valuations.
The Medicare Physician Fee Schedule Final rule (page 1923), in particular, illustrates that most of the simple emergency department laceration codes have been reassigned to a 0 day global package with a subsequent decrease in RVUs.
For example, some of the most common emergency department laceration repairs and their new valuations are represented in Table 2.
Physician Quality Reporting Initiative (PQRI) has a new name
CMS has changed the name of the PQRI program to “Physician Quality Reporting System” (PQRS) and continues expanding the program and making it more permanent. The new law extends the program through 2014. Payment bonuses to eligible professionals will equal 1% of estimated total allowed fee schedule services for 2011 and .05% for 2012-2014. In 2015, the payment is replaced by a penalty of 1.5% for not meeting the reporting requirements, which increases to 2% for 2016 and beyond.
Significant changes to emergency department-appropriate measures are not anticipated for 2011. Final measures and specifications (when available) can be viewed at www.cms.gov/pqri. Importantly, CMS will proceed with developing a “Physician Compare Website," which will provide data on providers who satisfactorily participate in the 2011 PQRS program.
CPT Changes for 2011
The American Medical Association’s annual update of the Current Procedural Terminology (CPT) codes and descriptions was also recently released and is effective for dates of service Jan. 1, 2011.
Beginning in 2011, emergency physicians will have a new option when reporting the middle day(s) of observation for stays that transcend 3 or more calendar days. This new code set is designated as “subsequent observation care” and is further delineated based on low, moderate, and high complexity as well as escalating documentation requirements.
The new subsequent observation codes include:
- 99224 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
- 99225 -- … an expanded problem focused interval history; an expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.
- 99226 -- … a detailed interval history; a detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.
CPT 2011 will also roll out a more specific set of extremity ultrasound codes replacing code 76880 (Ultrasound, extremity, nonvascular, real time with image documentation) with two new codes that differentiate a complete exam (76881) from a limited ultrasound exam (76882).
CPT also made significant changes to the debridement codes to achieve greater granularity. For 2011, codes 11040 (Debridement; skin, partial thickness) and11041 (Debridement; skin, full thickness) were deleted. Debridement of skin partial or full thickness must now qualify for active wound management, which is less commonly reportable by emergency physicians.
More substantial debridement involving subcutaneous tissue may be reported with two new codes:
- 11042 -- Debridement subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
- And the new add-on code 11045 -- each additional 20 sq cm, or part thereof (List separately in addition to code for the primary procedure)
Additional codes are available for more extensive debridement procedures, including:
- 11043 -- Debridement, muscle and/or fascia (includes epidermis and dermis, and subcutaneous tissue if performed), first 20 sq cm or less; and its new add-on code 11046 -- each additional 20 sq cm, or part thereof (List separately in addition to code for the primary procedure)
- 11044 -- Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia if performed), first 20 sq cm or less; and its new add-on code 11047 -- each additional 20 sq cm, or part thereof (List separately in addition to code for the primary procedure)
There are new influenza virus vaccination codes (90664-90668) for 2011 for products that represent a formulation of H1N1 vaccine in the event a new outbreak occurs prior to FDA approval for the vaccine products. The codes are available for the facility to report the vaccine administration.
In the emergency department setting, it is unlikely that the physician bears the cost of the vaccine, syringe and related supplies so they would be captured on the facility bill, rather than the physician’s professional fee.
The new codes are:
- 90664 -- Influenza virus vaccine, pandemic formulation, live, for intranasal use
- 90666 -- Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use
- 90667 -- Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use
- 90668 -- Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use
ICD-9 Diagnosis Codes for 2011
Effective Oct. 1 2010, several ICD-9 diagnosis codes became available that are relevant to emergency medicine. A full listing of ICD-9 additions, deletions, and change may be found at www.cdc.gov/nchs/icd/icd10cm.htm#10update.
Codes potentially applicable for the emergency department include:
- 276.69 -- Other fluid overload
- 560.32 -- Fecal impaction
- 780.33 -- Post traumatic seizures
- 784.92 -- Jaw pain
- 786.30 -- Hemoptysis, unspecified
- 799.50 -- Unspecified signs and symptoms involving cognition
- 970.81 -- Poisoning by cocaine
- 970.89 -- Poisoning by other central nervous system stimulants
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 are also available to field your questions. Finally, ACEP offers well-attended and highly recommended coding and reimbursement educational conferences annually with the next offering Feb. 16-20 in Las Vegas.
About the Author: Dr. Granovsky is a member of ACEP’s Coding and Nomenclature Advisory Committee, and president of Medical Reimbursement Systems (MRSI), an emergency department billing and coding company.