ED Coding and Reimbursement Alert

Overall, ED payments should remain similar to what you got in 2015

If you're not interested in wading through all 1358 pages of the CMS's 2016 Fee Schedule released at the end of October, we've digested it for you and have the following advice to offer. Read on to find out what'll affect your reimbursement in the coming year.

Stability: According to CMS, emergency medicine is estimated to have a zero percent change in overall payments in 2016, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA. The assigned relative value units (RVUs) for the ED E/M codes and critical care are relatively stable from 2015, with some small decreases (in the hundredths decimal place) in the practice expense offset by small increases in the professional liability insurance (PLI) RVUs. Other specialties will see broader changes because of two major factors, he says.

Revisions to Misvalued Codes and a Technical Refinement to the Conversion Factor Balance Out ED Payment Changes

The first factor is the number of changes to RVUs for specific services resulting from the Misvalued Code Initiative, including the establishment of RVUs for new and revised codes, says Granovsky. Several specialties, notably gastroenterology and radiation oncology, will experience significant decreases in payments in some of their services as a result of widespread revisions to the structure and the inputs used to develop RVUs for the codes that describe particular services. Other specialties, including pathology and independent laboratories, will experience significant increases to payments for similar reasons.

The second factor relates to a technical improvement that refines the PLI RVU methodology, in which CMS proposed to make a technical improvement that will result in small negative impacts to the portion of physician payments attributable to malpractice for gastroenterology, colon and rectal surgery, and neurosurgery, Granovsky explains.

The final rule includes Table 62, which lists the estimated impact on total allowed charges by specialty. To put the emergency medicine experience in perspective, here is a sample of some of those estimates:

• Gastroenterology had the lowest estimated change at -4 percent
• Radiation Oncology had -2 percent
• Emergency Medicine had zero estimated change
• Pathology +8 percent
• Independent laboratory had the highest estimated change at +9 percent

Most other specialties had an estimated change of zero, with a few at +1 percent (dermatology, interventional radiology, plastic surgery) or -1 percent (colorectal surgery, neurology, neurosurgery, ophthalmology, vascular surgery), says Granovsky.

Also included in the final rule is Table 63 showing the impact of all the changes on representative actual code payments, says Granovsky.

Included in Table 63 are codes 99283 and 99292, which are expected to have no changes, while codes 99284, 99291 are expected to decrease by 1 percent , he adds.

Don't Expect a Boost in the Conversion Factor

CMS has explained previously that the impact of the Protecting Access to Medicare Act of 2014 (PAMA) established an annual target of 0.5 percent for reductions in physician fee schedule expenditures resulting from adjustments to relative values of yet to be identified misvalued codes for calendar years (CYs) 2017 through 2020 and set the target at 0.5 percent of the estimated amount of expenditures under the upcoming physician fee schedules for each of those 4 years.  Separately, the Achieving a Better Life Experience Act of 2014 (ABLE) accelerated the application of the Physician Fee Schedule expenditure reduction target to CY 2016, 2017, and 2018, and to set a 1 percent target for CY 2016 and 0.5 percent for CYs 2017 and 2018. As a result of these combined provisions, if the estimated net reduction for a given year is less than the target for that year, payments under the fee schedule will be reduced to make up the difference.

In the 2016 MPFS Final Rule, CMS estimated the CY 2016 net reduction in expenditures resulting from adjustments to relative values of identified misvalued codes for this year to be 0.23 percent. Since this does not meet the 1 percent target established by ABLE, payments under the fee schedule must be reduced by the difference between the target for the year and the estimated net reduction in expenditures (the "Target Recapture Amount").

As a result, CMS estimated that the CY 2016 Target Recapture Amount will contribute a reduction to the 2016 conversion factor of -0.77 percent. Combined with the 0.5% scheduled increase and the 0.02% required by budget neutrality leads to a net decrease of 0.3% to the 2016 Medicare conversion factor  with the Final Rule publishing a 2016 CF of $35.8279, says Granovsky.

The good news:  "We no longer have to worry about an SGR adjustment as in year past, but don't forget that the two percent sequester downward adjustment to the Medicare allowable payment is still in force in 2016," says Granovsky. "Although this is not a change from 2015, it will further impact your actual 2016 reimbursement," he adds.

You Can Get Paid for Advanced Care Planning Codes

Although actually new in the 2015 CPT^® book, codes 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate) and 99498 (...each additional 30 minutes [List separately in addition to code for primary procedure]) are significantly addressed in the 2016 final rule, says Granovsky.

The nitty gritty: You may recall that CPT^® describes an advance directive as a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.

The code preamble offers examples of written advance directives as a Health Care Proxy, Durable Power of Attorney for Health Care, Living Will, and Medical Orders for Life-Sustaining Treatment (MOLST). 

There is also important language saying that when using codes 99497, 99498, no active management of the problem(s) is undertaken during the time period reported. CPT^® says that codes 99497, 99498 may be reported separately if these services are performed on the same day as another E/M service and specifically includes the ED E/M 9928x codes among those for which ACP codes may be reported, Granovsky explains.

Tip:  Providers should keep in mind the code requirements and specifically the 30 minutes in the code definition.

Then: In the 2015 PFS final rule, CMS assigned an interim final status indicator of ''I'' (Not valid for Medicare purposes). Medicare uses another code for the reporting and payment of these services to CPT^® codes 99497 and 99498 for CY 2015, saying it would consider whether to pay for codes 99497 and 99498 after it had the opportunity to go through notice and comment rulemaking.

Now: True to its word, in 2016 PFS final rule, CMS assigned codes 99497 and 99498 status indicator "A," which is defined as an "active code" and therefore separately payable under the Medicare physician fee schedule would be reported when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury, says Granovsky.  The services could be paid on the same day or a different day as other E/M services including the ED E/M codes 99281-99285.

However, CMS also adopted the CPT^® guidance prohibiting the reporting of codes 99497 and 99498 on the same date of service as certain critical care because they are also time-based codes, he adds.

The ACP RVUs assigned for 2016 are:

No National Coverage Decision For 2016

Although the advanced care planning codes have a status "A" indicator in the 2016 physician fee schedule, that does not mean that Medicare has made a national coverage determination regarding the service. In the absence of a national Medicare policy, local contractors remain responsible for local coverage decisions. CMS speaks to this decision in the final rule, saying that it believes it may be advantageous to allow time for implementation and experience with ACP services, including identification of any variation in utilization, before considering a controlling national coverage policy through the National Coverage Determination process. CMS plans to monitor utilization of the codes 99497 and 99498 over time to ensure that they are used appropriately, but until any national coverage determination is on place, you should check with your local MAC for any regional policies, warns Granovsky.

Who Can Report ACP Codes?

The CPT^® code descriptors state that the ACP services can be furnished by physicians or other qualified health professionals, which for Medicare purposes is consistent with allowing these codes to be billed by the physicians and NPPs in the ED whose scope of practice includes the services described by the codes and who are authorized to independently bill Medicare for those services. Therefore only these practitioners may report codes 99497 or 99498 and not other ancillary staff. CMS makes special mention that "incident to" rules apply when these services are furnished incident to the services of the billing practitioner, including a minimum of direct supervision.

The bottom line: So in the ED setting where "incident to" rules don't apply, the service must be performed by the physician or NPP reporting the service, says Granovsky.

CMS is on record that ACP services are appropriately furnished in a variety of settings, depending on the condition of the patient, and, CPT^® specifically includes the ED E/M codes among those for which ACP codes may be reported in the preamble to the advance care planning section.

CMS will continue to consider whether additional standards, special training or quality measures may be appropriate in the future as a condition of Medicare payment for ACP services.

CMS intentionally did not propose to add ACP services to the list of Medicare telehealth services, because the face-to-face services described by the codes need to be furnished in-person in order to be reported to Medicare, explains Granovsky.