Emergency medicine will see a very small decrease in our overall RVU values

On Nov. 1, 2011, the Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician Fee Schedule Final Rule, which addresses changes to the physician fee schedule, as well as other important Medicare part B payment policies. The rule is effective beginning Jan. 1, 2012, and is published in the Nov. 28, 2011, issue of the Federal Register.

The 2012 Conversion Factor

The year 2011 ended with a Medicare conversion factor (the Medicare payment per relative value unit [RVU]) of $33.9764. The dreaded Sustainable Growth Rate (SGR) formula remains on the books, and with the expiration of the latest congressional “patch” on Feb. 29, 2012 (as of press time), the 2012 Final Rule published a conversion factor of $24.6712, representing a 27.4% cut to physician payments. With a familiar chorus of physician pleading ringing in their ears, members of Congress staved off our execution each year since 2003 with a variety of short-term patches.

emergency medicine will experience a –1% update to our overall rvu values in 2012.

Emergency Department RVUs

According to the CMS specialty-specific impact analysis, emergency medicine will see a very small decrease in our overall RVU values. As published in the 2012 rule, emergency medicine will experience a –1% update to our overall RVU values in 2012. This is independent of any change to the conversion factor.

The RVUs for our major reimbursement drivers, the E/M codes, have only second decimal point adjustments, predominantly because of small changes in practice expense. Of note, the work RVUs have not changed for 2012 and remain stable at 2011 levels (Table 1).

Other services frequently provided by emergency physicians have also had their RVUs adjusted by the 2012 rule. For 2012, the Initial and Subsequent Observation Codes will see large gains (Tables 2 and 3).

Additionally, the RVUs for many emergency department procedures were impacted by the 2012 rule. CPR will see a roughly 5% increase, while the code for complex abscess drainage – a common ED procedure – will increase by almost 9%. The laceration codes were a mixed bag. Many of the superficial laceration codes were decreased slightly and a few of the intermediate codes were increased.

For a detailed analysis of the impact of the 2012 RVUs on key emergency department procedures, visit the ACEP website at www.acep.org and click on the reimbursement link.

Telehealth Expansion Includes Emergency Department Services

Telehealth services are expanding, in part because of the CMS vision of promoting greater integration of the health care delivery system, and now include the emergency department as a qualified site.

For 2012, Medicare is changing the code descriptors for the telehealth codes and expanding the definition beyond inpatients to include the emergency department (Table 4). The originating site’s reimbursement has been increased modestly as well, by 0.6%.

Regulatory Update: The Physician Quality Reporting System (PQRS) continues with a 0.5% bonus for successful reporting in 2012, which will continue through 2014 and transition to the penalty phase beginning in 2015. The CMS Physician Compare website is now live and being populated with basic physician-identifying information. In the 2012 rule, CMS reiterated its commitment to posting physician quality data, such as PQRS scores, on the website for 2013.

CMS has continued its interest in bundling “like procedures” and imposing discounts when multiple services are provided in a single setting. This discounting paradigm, termed Multiple Procedure Payment Reduction (MPPR), was previously limited to the facility or technical component of imaging. It has now been expanded to include the professional component of CTs, MRIs, and ultrasounds. Under MPPR, subsequent studies will trigger a 25% discount. The higher-priced study will be paid at the full fee schedule, and the second study will be discounted. Emergency department ultrasounds fall into the MPPR category of potentially discounted services, and emergency physicians may see expansion of this concept into other areas of diagnostic services.

CPT Coding Changes for 2012

Beginning in 2012 there are several CPT code changes of interest to emergency physicians. Taken from the 2012 CPT book, the highlights below should be incorporated starting Jan. 1.

In the Evaluation and Management (E/M) services guidelines in the front of the book, there is new wording inserted in the section describing the distinction between a New and Established Patient. The definition of a new patient is stated as one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty, who belongs to the same group practice, within the past 3 years.

Similarly, an established patient is one who has received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past 3 years.

The emergency department E/M codes 99281-99285 are not directly impacted by this language. However, if your group staffs an urgent care center, the distinction between new and established patient plays a critical role in determining the code selected for the visit and subsequent reimbursement. Reimbursement for patients classified as “established” is often 30% lower than that of “new” patients.

With greater integration, and with emergency department groups, urgent care centers, and multispecialty groups participating in myriad practice models, the updated language in CPT will help to clarify the patient’s status for payers and prevent visits from inappropriately being classified as “established.”

Changes to Observation Codes

The initial observation codes (99218-99220) have been updated with a new listing of typical times spent at the bedside and on the patient’s floor or unit. Those times now appear as 30 minutes for 99218, 50 minutes for 99219, and 70 minutes for 99220.

Typical times do not appear in the descriptors for observation services codes 99234-6 for CPT 2012.

These typical time additions to the subsequent observation codes come into play with new language in the prolonged services codes.

Code 99356 (Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient Evaluation and Management service) has a new parenthetical list of applicable code ranges that now include the initial admit to observation codes. (Use 99356 in conjunction with 99218-99220, 99221-2-99223, 99251-99255, 99304-99310, 90822, and 90829.) Of note, CPT Errata added the subsequent observation codes (99224-99226) to this code range parenthetical for use with prolonged service codes.

Effective Oct. 1, 2011, several icd-9 diagnosis codes became available that are relevant to emergency medicine.

Time Not a Factor in ED Code Selection

New “Coding Tips” appear in the CPT E/M section about the significance of time as a factor in the selection of certain E/M codes. This is not a new concept but provides a reminder that the inclusion of time is there to assist physicians in selecting the appropriate E/M level. However, it has been a long-standing tenet within CPT that time is not a factor in selecting the appropriate emergency department level of service. The inclusion of the separately delineated emergency department “coding tip” reiterates that time is not a factor in selecting emergency department E/M codes “since services are provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.”

There is a small but meaningful change in the laceration repair code preamble replacing the instruction to report wound repairs of different classification, as well as those involving nerves, blood vessels, and tendons in a complex repair using modifier -59 (Distinct procedural service) rather than -51 (Multiple procedures) as in years past. This should help to identify to the payers truly separate repairs that should be fully reimbursed rather than be subject to a significant decrease in payment.

There are new codes 49082-49083 for Abdominal paracentesis (diagnostic or therapeutic) with and without imaging guidance, and 40824 (Peritoneal lavage, including image guidance when performed).

A complete list of all the changes for 2012 can be found in Appendix B summary of Additions, Deletions, and Revisions found on page 572 of the 2012 CPT book.

ICD-9 Diagnosis Codes for 2011

Effective Oct. 1, 2011, several ICD-9 diagnosis codes became available that are relevant to emergency medicine. A full listing of ICD-9 additions, deletions, and changes may be found at www.cdc.gov/nchs/icd/icd10cm.htm#10update.

Although everyone is anticipating the transition to ICD-10 in October of 2013, there are some useful new diagnosis codes available for emergency physicians to demonstrate medical necessity for their claims based on the latest ICD-9 updates. Consider these ICD-9 code changes for dementia, which more clearly indicate how the disease impacted the care provided in the emergency department, including inability to obtain the normal history or physical exam requirements:

• New sub: 294.2 Dementia, unspecified (excludes mild memory disturbances, not amounting to dementia [310.89])
• New code: 294.20 Dementia, unspecified, without behavioral disturbance
• New code: 294.21 Dementia, unspecified, with behavioral disturbance

These new codes are an additional arrow in the quiver to prove to the payer the medical necessity for the visit.

Other ED-Relevant New ICD-9 codes

These new ICD-9 codes detail influenza with other specific respiratory manifestations:

• 488.81 Influenza due to identified novel influenza A virus with pneumonia
• 488.82 Influenza due to identified novel influenza A virus with other respiratory manifestations
• 488.89 Influenza due to identified novel influenza A virus with other manifestations

These new ICD-9 codes detail causes of anaphylactic shock and other reactions with greater specificity:

• 999.41 Anaphylactic reaction due to administration of blood and blood products
• 999.42 Anaphylactic reaction due to vaccination
• 999.49 Anaphylactic reaction due to other serum
• 999.51 Other serum reaction due to administration of blood and blood products
• 999.52 Other serum reaction due to vaccination
• 999.59 Other serum reaction

These new V codes expand the list of factors influencing health status and contact with health services that could help explain the reason for an ED visit:

• V12.21 Personal history of gestational diabetes
• V12.29 Personal history of other endocrine, metabolic, and immunity disorders
• V12.55 Personal history of pulmonary embolism
• V13.81 Personal history of anaphylaxis
• V13.89 Personal history of other specified diseases
• V23.42 Pregnancy with history of ectopic pregnancy
• V23.87 Pregnancy with inconclusive fetal viability
• V40.39 Other specified behavioral problem

Be sure to review the guide to the 2012 ICD-9 CM Updates published in the front of the diagnosis code, which notes changes effective for 2012. A complete listing of the ICD-9 code changes for 2012 (effective Oct. 1, 2011) is available on the CMS website at www.cms.gov/icd9providerdiagnosticcodes/07_summarytables.asp.

Other Resources

Resources for these and other topics can be found in 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 at 800-798-1822, ext 3232.

Finally, ACEP offers well-attended and highly recommended coding and reimbursement educational conferences annually, with the next offering taking place Jan. 23-27 in Las Vegas.

Dr. Granovsky is president of LogixHealth, an ED coding and billing company, and currently serves as chair of ACEP’s Coding and Nomenclature Advisory Committee.