The 2017 Medicare physician fee schedule was released on Nov. 2, 2016, with mostly good news for emergency medicine. As anticipated, there were minimal changes to the ED evaluation and management (E/M) codes, critical care, and observation service values in 2017. Table 52 of the final rule lists the estimated impact by specialty based on changes to the work, practice expense, and professional liability insurance relative value units (RVUs) for 2017. Most of the specialties listed, including emergency medicine, had an estimated impact of 0 percent in overall revenue being changed. There were a few winners, such as anesthesiology, family practice, internal medicine, and geriatrics, with a 1 percent increase, which is likely due to changes in the coordination of care codes for the primary care specialties. The losers in 2017 were gastroenterology, interventional radiology, and pathology, with 1 percent decreases; urology, with a 2 percent decrease; and independent lab, with a 5 percent decrease. Keep in mind that rounding can play a big role in whether you are plus or minus 1 percent or end up with an estimated zero change.

Conversion Factor Increases

Based on Protecting Access to Medicare Act of Half Percent Update The Medicare Access and CHIP Reauthorization Act (MACRA) mandated a 0.5 percent increase to the conversion factor for 2017. Several other factors also played a role with small negative adjustments. A negative budget neutrally adjustment factor impacted the 2017 conversion factor to offset overall increases in RVUs relative to 2016 as well as a target recapture update of -0.18 percent related to misvalued codes. The net impact is an increase of about $0.08 to the 2017 conversion factor, as shown in Table 50 from the final rule, with a published conversion factor of $35.8887.

Changes for Emergency Medicine in CPT 2017

There were no significant changes in the E/M code section and just the usual updating of the vaccine codes in the medicine section relating to tweaks to the composition or dosage information. For example, influenza codes will now be coded by dosage rather than age. The biggest change for emergency medicine is a new series of moderate (conscious) sedation codes.

The prior moderate (conscious) sedation codes (99143–99150) have been deleted and replaced with new codes (99151–99157). The new codes look similar in that there are three codes describing moderate sedation for both the scenarios where the sedation is provided in support of your own procedure and for another provider’s procedure. The three codes for each of these scenarios describe one code for patients younger than age 5, one for age 5 and older, and an add-on code for additional time providing moderate sedation.

Physicians will see a small $0.08 increase to the Medicare payment per RVU in 2017.

The biggest change is that the intraservice time thresholds have dropped from 30 minutes to 15 minutes. Current Procedural Terminology (CPT) instructs that for any time-based code, a unit of time is attained when the midpoint is passed unless there are code- or code range–specific instructions in the guidelines, parenthetical instructions, or code descriptors to the contrary. In 2017, there is a chart, similar to the one in the critical care code section, which lists the correct moderate sedation code to assign based on the provider situation and the total intraservice time. The CPT moderate sedation table shows that sedation services would now be reportable once the physician exceeds 10 minutes of intraservice time.

Intraservice time begins with the administration of the sedating agent; requires continuous face-to-face attention of the provider and monitoring of the patient’s response to the sedation, periodic reassessments, and vital signs including oxygenation, heart rate, and blood pressure; and ends when the procedure is completed, the patient is stable, and the provider providing sedation ends personal face-to-face care of the patient.

New Modifier 95 for Synchronous Telemedicine Services

As telemedicine technology continues to improve, there has been an increasing demand for an accepted mechanism to identify and report services provided by a remote physician. The CPT editorial panel considered this issue for many years before a joint CPT and Relative Value Scale Update Committee Telehealth Services workgroup was convened to make a recommendation on how best to move forward. In 2017, CPT added modifier 95 (synchronous telemedicine services rendered via real-time interactive audio and video telecommunications system) for use in identifying services provided via telemedicine.

The modifier descriptor specifies that the service must be synchronous, meaning in real time, for correct application. The qualified provider must be using real-time audio and video telecommunications between the patient and the distant site in which the provider practices, and the totality of the information exchanged must be commensurate with the key components or other requirements to have reported the service or procedure as if the distant provider were physically present with the patient.

Additionally, the 2017 CPT book added new Appendix P, which lists codes that may be used for reporting synchronous telemedicine services when using interactive telecommunications equipment that includes, at a minimum, audio and video. The codes listed in Appendix P will now be marked with a star symbol (☆) where they appear normally in the book.

However, no ED E/M or observation codes appear in Appendix P. The codes selected for inclusion were based on a search of payer policy requiring the use of the Healthcare Common Procedure Coding System Level II synchronous modifier with CPT codes. The ED codes did not come up anywhere in those payer policies so were not included in Appendix P. ACEP is exploring how they can be added in future years with evidence that ED services are widely recommended for performance via synchronous real-time communication.

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Dr. Granovsky is the president of Logix Health, an ED coding and billing company, and serves as the course director of ACEP’s coding and reimbursement courses as well as ACEP’s National Reimbursement Committee. Mr. McKenzie is reimbursement director for ACEP.