The Centers for Medicare and Medicaid Services (CMS) issued the Medicare Physician Fee Schedule Final Rule on 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 from Jan. 1, 2011, and contains a significant decrease in physician rates with a Medicare conversion factor (Medicare’s reimbursement per relative-value unit [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, 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 from 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 cut and instead keep Medicare physician fees at their current rate throughout 2011. The American Medical Association praised Congress and the President for averting the Medicare cuts and giving the program some stability by passing a 1-year fix, as opposed to the short-term approach Congress took throughout 2010.

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 2 of a 4-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 the CMS has been significantly shortened. The 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

The RVUs for procedures are determined based on a methodology that takes into consideration preservice, intraservice, and postservice 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 (see Table 1).

The Medicare Physician Fee Schedule Final Rule (page 1923) can be found online at acep.org/reimbursement. In particular, most of the simple emergency department laceration codes have been reassigned to a 0-day global package with a subsequent decrease in RVUs. Some of the most common emergency department laceration repairs and their new valuations are shown in Table 2.

PQRI Now PQRS

The CMS has changed the name of the Physician Quality Reporting Initiative (PQRI) to the 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 0.05% 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, the CMS will proceed with developing a “Physician Compare” Web site, which will provide data on providers who satisfactor­ily participate in the 2011 PQRS program.

Other Resources

Details of the American Medical Association’s annual update of the Current Procedural Terminology (CPT) codes and descriptions can be found online at acep.org/reimbursement. There are also details about the ICD-9 diagnosis codes at that same Web site.

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.

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.