The 2019 Medicare Physician Fee Schedule Proposed Rule was released on July 12, 2018, and it includes significant proposed changes from the Centers for Medicare and Medicaid Services (CMS) relevant to emergency medicine. ACEP has submitted robust commentary on it. The Final Rule should be released in November and go into effect Jan. 1, 2019.

Here are some emergency medicine–related highlights from the Proposed Rule.

RVU Remains Stable

Each year, based on several technical formulas, CMS publishes the Medicare reimbursement rate per relative value unit (RVU, ie, the conversion factor). Many private payers then incorporate the Medicare changes when considering their own rates, so this conversion factor has far-reaching economic implications.

The proposed 2019 conversion factor of $36.0463 represents a slight increase from 2018’s $35.9996. Following a low point in 2011, the conversion factor has generally increased and is no longer governed by the flawed Sustainable Growth Rate formula (see Figure 1).

(click for larger image) Figure 1: CMS Payment Per RVU

The RVU Value of ED Codes

At the end of last year, the 2018 Physician Final Rule highlighted concerns that emergency department evaluation and management (E/M) services may be undervalued:

“We received information suggesting that the work RVUs for emergency department visits did not appropriately reflect the full resources involved in furnishing these services. We agree with the majority of commenters that these services may be potentially misvalued given the increased acuity of the patient population. As a result, we look forward to reviewing the RUC’s recommendations regarding the appropriate valuation of these services for our consideration in future notice and comment rulemaking.”

ACEP’s Relative Value Update Committee recently presented the ED E/M codes (99281–99285) that make up 83 percent of our RVUs for valuation by the Relative Value Scale Update Committee (RUC). Although the RUC’s deliberations remain confidential, I can say the ACEP committee mounted vigorous arguments defending the increase in the acuity of our patients, and CMS is currently considering the RUC’s recommendations.

ED Codes Not Affected

Toward the end of 2018, CMS expressed dissatisfaction with the widely applied 1995 Documentation Guidelines for Evaluation and Management Services, stating they may not reflect today’s more electronic clinical documentation processes:

“The guidelines have not been updated to account for significant changes in technology, especially electronic health record (EHR) use, which presents challenges for data and program integrity and potential upcoding, given the frequently automated selection of code level. In the near-term, it may be possible to eliminate the current focus on details of history and physical exam, and allow MDM [medical decision making] and/or time to serve as the key determinant of E/M visit level.”

For 2019, CMS has proposed significant changes to the documentation guidelines for the office visit/urgent care codes but has elected not to apply these changes to the more complex ED environment. The new patient and the established patient office visit codes would be collapsed for levels 2–5, with a single payment rate and the ability for the provider to choose the current 1995 documentation guidelines or perhaps score it simply based on MDM or time.

ED Documentation Not Impacted

CMS also proposes leaving ED codes alone:

“We are not proposing any changes to the emergency department E/M code set or to the E/M code sets for settings of care other than office-based and outpatient settings at this time. However, we are seeking public comment on whether we should make any changes to it in future years, whether by way of documentation, coding, and/or payment and, if so, what the changes should be.”

Teaching Physician Documentation

In an effort to reduce the physician documentation burden, CMS proposes eliminating duplicative documentation requirements for teaching physicians (TPs) when the required information has already been documented by someone else. CMS specifically proposes the following:

“The medical records must document the extent of the teaching physician’s participation in the review and direction of services furnished to each beneficiary, and that the extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.”

If this documentation relief is enacted, TPs would be spared from re-documenting large components of the medical record, and a TP’s involvement could be recorded by another physician, resident, or nurse.

In another win for TPs, Medicare issued a regulatory update related to medical student documentation, clarifying that the TP does not have to re-document items in the medical record entered by medical students, and although the TP must perform the components of the medical service (such as a physical exam and MDM), they do not have to re-document a full note. Just a TP signature is required following the medical student’s documentation:

“If the teaching physician chooses to rely on the medical student documentation and chooses not to re-document the E/M service, contractors shall consider this requirement met if the teaching physician signs and dates the medical student’s entry in the medical record.”

Dr. Granovsky is the president of LogixHealth, an ED coding and billing company, and serves as the course director of ACEP’s coding and reimbursement courses. Email him questions at mgranovsky@logixhealth.com.

Documentation School

For more information on ED documentation issues, check out these classes at ACEP18 in October:

• Rev Up Your Procedural and Critical Care RVUs: Wednesday,
  Oct. 3, 8–8:50 a.m.
• RVU Killers: The Most Common Reimbursement Documentation Errors:
  Thursday, Oct. 4, 8–8:25 a.m.