ED Coding and Reimbursement Alert

Check these RVU changes to calculate your 2012 payments

If you were hoping for a reprieve in 2012 from the recession cost pressures on EDs, the word is that you can expect an overall decrease of 1.5 percent in 2012 CMS payments. Read on for how this all breaks down and will affect your ED billing.

2012 fee schedule facts: The Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician fee schedule Final Rule Nov. 1, 2011, 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 was published in the Nov. 28, 2011 Federal Register.

Look For Small ED E/M RVUs Decreases

According to the 2012 final rule, emergency medicine will experience a -1 percent update to overall RVU values in 2012. This is independent of any change to the conversion factor.

The RVUs for ED E/M codes, the dominant factor in determining ED reimbursement, have only second decimal point adjustments predominantly due to small changes in practice expense. Of note, the work RVUs have not changed for 2012 and remain stable at 2011 levels, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, an ED coding and billing company in Bedford, MA.

See the chart below to compare the specific RVU E/M code breakdown for 2011 and 2012:

Expect More Pay for Initial, Subsequent Observation

The good news is that you can look for large RVU gains for initial and subsequent observation care services, while the same day observation admit and discharge codes will remain close to the 2011 values. The following charts outline the changes:

Prep For Pay Upticks for These ED Procedures

The 2012 RVUs assigned to complex abscess drainage 10061 (Incision and drainage of abscess [e.g. carbuncle, suppurative hidradentits , cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple) will increase by almost 9 percent and the CPR code 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest] will experience a 5 percent increase. The intermediate laceration codes had varied results. Some of the code work RVUs were decreased slightly and a few of the intermediate code values were increased.

Telehealth Coverage For ED Services Gets Green Light

And more good news for EDs providing telehealth services: CMS has expanded its telehealth site promotion to include EDs, which means EDs are now qualified site for telehealth coverage. The ED was not considered a qualified site of services previously, but for 2012, Medicare is creating new code descriptors for the telehealth codes. The definition is now being expanded beyond inpatients and includes the emergency department, says Granovsky.

The 2012 ED telehealth codes, descriptors, and assigned RVUs are listed below. The originating site's reimbursement has been increased as well by 0.6 percent.

Don't Overlook 2012 PQRS, MPPR Changes

You can still qualify for a bonus payment because the PQRS (Physician Quality Reporting System) continues for 2012 with a 0.5 percent bonus for successful reporting, notes Granovsky. The 0.5 percent bonus will continue through 2014 and transition to the penalty phase beginning in 2015. The CMS Physician Compare website is now live and basic physician identifying information is starting to be populated. (The web site can be found at http://www.medicare.gov/find-a-doctor/provider-search.aspx)

CMS, in the 2012 rule, continued to demonstrate their commitment to posting physician quality data, such as PQRS scores, on the website for 2013.

Ultrasounds take a hit: when those services are discounted under MPPR rules.

CMS has continued its interest in bundling "like procedures" and imposing discounts when multiple services are provided in a single setting, Granovsky adds. This discounting system, the Multiple Procedure Payment Reduction (MPPR), was previously limited to the facility or technical component of imaging. The program has been expanded to include the professional component of CTs, MRIs, and ultrasounds. Under MPPR, subsequent studies will be discounted by 25 percent. The higher priced study will be paid at the full fee schedule and the second study will be paid at 75 percent of the physician fee schedule. Unfortunately, ED ultrasounds fall under the MPPR designation, and we may see expansion of this discounting into other areas of diagnostic services, he explains.