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ACEP Now: Vol 37 – No 12 – December 2018

(click for larger image) Table 2: Calculation of the Proposed CY 2019 Physician Fee Schedule Conversion Facto

The small increase for 2019 is consistent with the trend of the final conversion factor value sticking to a fairly tight range, though it has been some time since we have broken through the $36 mark (see Figure 1).

Documentation Guideline Reform Not for ED Codes

CMS has expressed a desire to move away from the “bean counting” history and exam requirements of the 1995 documentation guidelines and place a greater emphasis on documented time and medical decision making, a position that has been well supported by the provider community:

“Stakeholders have long maintained that all of the E/M documentation guidelines are administratively burdensome and outdated with respect to the practice of medicine. Stakeholders have told CMS that they believe the guidelines are too complex, ambiguous, fail to meaningfully distinguish differences among code levels, and are not updated for changes in technology, especially electronic health record (EHR) use.” —2019 Medicare Physician Fee Schedule Final Rule

CMS has opted for a measured approach to updating the documentation guidelines. While there will be no changes to the emergency department code documentation requirements, the office visit codes will undergo a major restructuring in two years (2021). For 2019 and 2020, CMS will continue the existing documentation requirements. Starting in 2021, CMS will create a single code for new and established E/M office/outpatient visit levels 2 through 4 and keep level 5 separate.

Teaching Physician Documentation Guidelines Updated

CMS has worked to decrease the potential for duplicative documentation in academic medical settings.

“The purpose of these revisions to the regulations is to eliminate potentially duplicative requirements for notations that may have previously been included in the medical records by residents or other members of the medical team. The teaching physician continues to be responsible for reviewing and verifying the accuracy of notations previously included by residents and members of the medical team, along with further documenting the medical record if the notations previously provided did not accurately demonstrate the teaching physician’s involvement in an E/M service.” —2019 Medicare Physician Fee Schedule Final Rule

However, unlike prior Teaching Physician guidance (Medicare Transmittal 1780 and 811), which provided examples of acceptable and unacceptable documentation, the 2019 Physician Final Rule does not provide such examples. Absent specific examples, ACEP will be asking CMS for further clarity.

Telemedicine is Gaining Acceptance in 2019, But Not Yet for ED Use

In an effort to expand the use of telehealth in Medicare, CMS will begin to pay separately for two newly defined physician services furnished using communication technology:

1. Brief Communication Technology-Based Service: This service will cover a “virtual check-in” by a patient via telephone or other telecommunications device to decidewhether an office visit or other service is needed.
2. Remote Evaluation of Recorded Video and/or Images Submitted by the Patient: This service will allow practitioners to be separately paid for reviewing a patient-transmitted photo or video information (such as by text message) to assess whether a visit is needed.

However, each of these codes are intended for use only with established patients, which will limit their use in the typical emergency department setting.

Combatting the Opioid Crisis

Importantly, beginning in July 2019, a patient’s home will be eligible to be the originating site for telehealth services for opioid and substance abuse disorder treatment or co-occurring mental health disorders, which could help reduce the opioid crisis and related emergency department visits.

Few CPT Changes for Emergency Medicine in 2019

There were no significant changes in the E/M code section of CPT and just the usual updating of the vaccine codes in the medicine section relating to tweaks of the composition or dosage information, including 18 changes in codes for influenza vaccines.