ED Coding and Reimbursement Alert

Plus: The updated fee schedule also includes changes to the conversion factor, telehealth list.

If you were expecting good news from this year’s Medicare Physician Fee Schedule (MPFS) release, you’ve got it. But if you were expecting bad news from the document, you’ll be facing that as well. Because of the ups and downs of this year’s MPFS, reading the 1,994-page document might be a roller coaster, but we’ve got the scoop on the issues most important to EDs.

Background: CMS has released the 2021 MPFS, which will impact emergency medicine reimbursement significantly. The final rule dropped on Nov. 30, 2020, a month later than usual due to the public health emergency (PHE). A more in-depth analysis will be included in next month’s issue, but we’re sharing six points you need to know now.

1. 2021 RVUs Increase for ED E/M Services

Acting to protect the safety net, The American College of Emergency Physicians (ACEP) asked CMS to recognize the intensity of ED services and maintain the relativity between the ED E/M codes and the new patient office codes, which received increased values in 2021. “CMS has agreed with the relativity arguments made by ACEP, and as a result, our 2021 work RVUs [relative value units] will be increasing significantly for 99283-99285 (Emergency department visit for the evaluation and management of a patient …),” said Michael Granovsky MD, CPC, FACEP, president of LogixHealth.

To get a complete view of how the work RVUs will change this year, check out the following table:

2. Conversion Factor Drops

If you were hoping for an increased conversion factor, unfortunately CMS wasn’t able to deliver this year. The agency has imposed a 2021 MPFS conversion factor of $32.4085, a 10.2 percent decrease from the 2020 rate of $36.0896. This historic decrease was due to CMS’ decision to increase reimbursement for the office visit codes (99202-99215), a boon for urgent care centers (which use outpatient E/M codes). However, this increased spending triggered a significant budget neutrality adjustment, as required by law.

Due to the statutorily mandated budget neutrality adjustment to the conversion factor, emergency medicine could experience as much as a 6 percent net decrease in reimbursement. Although CMS declined to waive the budget neutrality cuts, using special waivers during the PHE, Congress has the power to fix this by waiving the budget neutrality requirement. If Congress acts, emergency medicine reimbursement could actually increase by about 4 percent, instead of decreasing by 6 percent. ACEP and other organizations are calling on Congress to update the conversion factor.

“The AMA strongly urges Congress to prevent or postpone the payment reductions resulting from Medicare’s budget neutrality requirement,” said American Medical Association President Susan R. Bailey, MD, in a statement. “Physicians are already experiencing substantial economic hardships due to COVID-19, so these payment cuts could not come at a worse time.”

3. Check Changes to Telehealth Services

CMS made a determination about which of the codes that are temporarily on the list of approved Medicare telehealth services during the COVID-19 PHE will remain on the list permanently. The agency agreed to keep ED E/M code levels one through five (99281-99285), critical care, and observations codes on the list of approved Medicare services through the duration of year when the PHE expires (currently until December 31, 2021). Unfortunately, CMS did not add any of these codes to the permanent approval list for telehealth, citing these services as too intense to be routinely performed via telehealth.

In addition, many services under the MPFS can be delivered by auxiliary personnel under the direct supervision of a physician. In these cases, the supervision requirements necessitate the presence of the physician in a particular location, usually in the same location as the beneficiary when the service is provided. During the PHE, CMS is temporarily modifying the direct supervision requirement to allow for the

virtual presence of the supervising physician using interactive audio/video real-time communications technology.

In the rule, CMS is extending this policy until whichever is later: the end of the calendar year in which the PHE ends or December 31, 2021. For rural settings only, CMS has made oversight via telemedicine permanent for teaching physician supervising residents in residency training sites outside of an OMB-defined metropolitan statistical area.

4. Nonphysician Practitioners See New Supervision Rules

Under the new MPFS, CMS will allow nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives to supervise the performance of diagnostic tests. CMS granted this flexibility during the COVID-19 PHE and is now going to extend it permanently. The agency expressed concern about ensuring an adequate workforce is areas where there are shortages and seeks information about states that have scope of practice laws in place.

Moonlighting resident flexibilities, allowing an emergency medicine resident to work elsewhere outside the scope of their residency duties, have been extended to December 31, 2021 or may be made permanent to help cover physician shortages due to the PHE.

5. Check These Medical Documentation Requirements

In last year’s rule, CMS finalized numerous changes to the medical record documentation requirements for physicians and other healthcare practitioners. In the new 2021 final rule, CMS that physicians and other healthcare practitioners, including therapists, can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the MPFS.

6. Look for MIPS Updates

The MPFS includes several updates to the Merit-based Incentive Payment System (MIPS) that will be of strong relevance to emergency physicians:

• 2020 Reporting Exemptions Due to COVID-19: CMS is granting hardship exemptions on a case-by-case basis due to COVID-19. It is therefore possible for a clinician or group to request exemption from all four performance categories in 2020. If clinicians submit a hardship exception application for all four MIPS performance categories, and their application is approved, they will be held harmless from a payment adjustment in 2022 — meaning that they will not be eligible for a bonus and not face a penalty based on their MIPS performance in 2020. The final rule also published a continuation of the hardship exception process for 2021.
• Performance Threshold: CMS has set the threshold that clinicians need to achieve to avoid a penalty in 2021 at 60 points. In the proposed rule, CMS had stated that the performance threshold would be 50 points in 2021, but CMS is now instituting a higher threshold.
• MIPS Value Pathways (MVPs): CMS is committed to developing MVPs, which would combine all four categories of MIPS reporting into a single, more harmonized process. However, due to COVID-19, the implementation of MVPs is being delayed until 2022.

Resource: To read the MPFS in its entirety, visit https://public-inspection.federalregister.gov/2020-26815.pdf.