The American Medical Association’s annual update of the Current Procedural Terminology codes and descriptions was recently released. Each year after the publication of the new CPT book, ACEP’s Coding and Nomenclature Advisory Committee provides a summary of the most relevant CPT changes for emergency medicine.

Of note for 2010, the musculoskeletal subsection has been greatly expanded to include new guidelines defining procedures related to excision of subcutaneous and other soft-tissue tumors.

A total of 41 new codes have been added. In addition, there is a new code (29581) to report the application of a multilayer venous wound compression system.

Effective Oct. 1, 2010, several ICD-9 diagnosis code additions and revisions appear that are relevant to emergency medicine:

• The diagnosis code set describing gouty arthropathy has been expanded and refined with several new codes, including gouty arthropathy, unspecified (274.00), gouty arthropathy, acute (274.01), chronic gouty arthropathy, without mention of tophus (274.02), and chronic gouty arthropathy, with tophus (274.03).
• There is a new code for acute chemical conjunctivitis (372.06).
• There is a significant expansion and refinement of the venous embolism and thrombosis code set.
• There is greater granularity in the reporting of viral illnesses including influenza due to identified avian influenza virus (488.0) and influenza due to identified novel H1N1 influenza virus (488.1).
• Several new codes describe vomiting with greater granularity, including vomiting of fecal matter (569.87), bilious vomiting in newborn (779.32), and other vomiting in newborn (779.33).
• A series of codes better describes alterations in a patient’s emotional state: nervousness (799.21), irritability (799.22), impulsiveness (799.23), and emotional lability (799.24).
• Several important pediatric codes include apparent life-threatening event in infant (799.82), torus fracture of ulna alone (813.46), torus fracture of radius and ulna (813.47), and nursemaid’s elbow (832.2).
• There are multiple new poisoning codes: by antidepressant, unspecified (969.00); by monoamine oxidase inhibitors (969.01); by selective serotonin and norepinephrine reuptake inhibitors (969.02); by selective serotonin reuptake inhibitors (969.03); by tetracyclic antidepressants (969.04); by tricyclic antidepressants (969.05); by other antidepressants (969.09); by psychostimulant, unspecified (969.70); by caffeine (969.71); and by amphetamines (969.72).

The 2010 ICD-9 book has a complete list of new and deleted codes.

Medicare Physician Fee Schedule 2010 Final Rule

On Oct. 30, 2009, Medicare released the Medicare Physician Fee Schedule Final Rule, with final publication in the Federal Register Nov. 25, 2009. The Final Rule sets payment rates for Medicare providers with rates going into effect beginning with dates of service Jan. 1, 2010.

While the relative value units (RVU) for emergency medicine codes increased slightly, the much-discussed cut to physician reimbursement mandated by the SGR formula (sustainable growth rate formula) was included in the rule and dictated a 21.2% decrease to overall physician reimbursement.

Each year since 2002, the SGR formula has yielded negative updates to Medicare’s reimbursement; and every year, Congress has stepped in to thwart the reduction. As global health care reform unfolds, stay tuned for timely updates on the ACEP Web site (www.ACEP.org) regarding the fate of physician reimbursement and other pressing reform issues.

Starting in 2010, Medicare has begun a transition to an alternate methodology for valuing the practice expense component of our payments, resulting in increased reimbursement for emergency medicine. The approximate 2% increase will be transitioned over a 4-year period and is based on the updated Physician Practice Inventory Survey (PPIS) data that ACEP helped fund.

See the accompanying table for a comparison of 2009 and 2010 Emergency Medicine RVUs.

Although emergency physicians don’t typically report consultations, it is worth noting that in 2010 CMS will no longer recognize the consultation codes. CMS is instructing providers to report those services using the office/other outpatient codes or initial hospital care codes, depending on the site of service. Emergency physicians likely won’t notice any direct impact on payment from this policy change, but it could factor into the availability of on-call specialists for ED consults.

In the area of electronic prescribing (E-Rx), bonuses that transition quickly to ongoing 2% penalties for those not performing E-Rx will continue in 2010. Because of the lack of direct physician control and the unique nature of emergency departments’ episodic and geographically varied patient population, CMS has elected to “carve out” the ED from the E-Rx program, and EDs will not be participating.

Physician Quality Reporting Initiative

CMS has currently published 153 PQRI measures, of which 9 potentially apply to the emergency department setting. The PQRI bonus for 2010 remains stable at 2%. As they become available, final specifications relating to the current year’s measures can be found on the Medicare Web site, www.cms.hhs.gov/pqri.

CMS has responded to physician concerns regarding difficulty obtaining PQRI reports. As a result, a new mechanism has been created to obtain PQRI feedback reports. Beginning in October 2009, individual physicians may call their respective Medicare carriers directly to obtain feedback reports based on their individual NPI numbers. A list of CMS contact centers can be found on the CMS Web site, www.cms.hhs.gov.

CMS has completed its analysis of 2008 PQRI data and initiated payment for those who successfully met the reporting requirements of 80% reporting for three measures. For the 2008 PQRI reporting period, CMS will pay out a total of $92 million dollars. In 2008, providers qualified for an average of $1,000, up from roughly $600 for the initial 6-month reporting period available in 2007.

Of note, three of the pneumonia measures were reported with significant success:

• Measure 59: Empiric Antibiotic for Community-Acquired Bacterial Pneumonia (97.18% success rate);
• Measure 58: Assessment of Mental Status for Community-Acquired Bacterial Pneumonia ( 97.22% success rate); and
• Measure 56: Vital Signs for Community-Acquired Bacterial Pneumonia (96.06% success rate).

Other Resources

Resources for these and other topics can be found on the reimbursement section of the ACEP Web site. The ACEP Coding and Nomenclature Advisory Committee, the ACEP Reimbursement Committee, and ACEP Reimbursement Department staff members are also available to field your questions. Finally, ACEP holds well-attended and highly recommended coding and reimbursement educational conferences twice a year.

Dr. Granovsky is a member of ACEP’s Coding and Nomenclature Advisory Committee. Dr. Granovsky is president of Medical Reimbursement Systems (MRSI), an ED billing and coding company.