ED Coding and Reimbursement Alert

Congress still has time to act, however.

The second the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS), the controversy began.

Why? The conversion factor (CF) for 2023. Barring some last-minute legislation, deep CF cuts are coming. The MPFS final rule was posted on Nov. 1, and reaction has been swift and universal. Providers aren’t seeing a silver lining in this fee schedule CF.

“My initial reaction to this change is ‘Wow, that’s a big decrease. There is no way that is not going to hurt physicians,’” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. Here’s some advice on how your practice can get ahead of the CF cut and keep its head above water in 2023.

Expert: CF ‘Disappointing’

For 2023, the final MPFS CF is $33.06, down $1.53 from the 20022 CF of $34.61.

To Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania, the CF number was “very disappointing, especially during an economic period characterized by high inflation where we would also expect positive adjustments in the [CF]. This is compounded by COVID-related challenges,” she says.

All is not lost, however. Congress could step in before the end of the year and change the CF. There will be pressure on Congress to act; at press time, it still had not address the MPFS.

Telehealth Expansion Brings Good News

“On a good note, CMS intends to adopt the telehealth waiver extension that Congress passed in Consolidated Appropriations Act of 2022,” says Falbo. “The extension locks in a wide range of telehealth waivers for 151 days after the PHE [public health emergency] expires, including the audio-only exceptions that have been popular with providers; the waiver of geographic and other limits ordinarily required for telehealth services; and the ability of therapists, occupational therapists, speech-language pathologists, and audiologists to bill such codes under telehealth.”

Additionally, the ED evaluation and management (E/M) codes are on the approved Category 3 code list for telehealth until the end of 2023, according to Medicare.

Practices Can Get Proactive to Offset CF Cut

Experts agree that there are a few aspects of coding your practice can control that could help streamline and maximize your reimbursement. Your adjustment to new reporting rules could be crucial in keeping your coding correct.

Remember: As with office/outpatient evaluation and management (E/M) codes in 2021, the AMA changed descriptors for several code sets in the other E/M sections of CPT®, including the ED E/M codes. In many cases, these changes mirror what the AMA did in 2021. The main feature of the E/M changes is that you will often be able to code based solely on time or medical decision making (MDM). Although a medially appropriate history and physical exam must be documented for the encounter, those elements no longer count towards selecting the level of service in 2023.

Time is not a factor in the 99281-99285 codes so ED visits will be scored by MDM.

However, for those ED groups providing observation services time may still be relevant. For instance, when reporting observation or hospital inpatient services such as 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/ or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.) or 99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.) — coders may score the visit by MDM or time.

“I think that at least part of the solution is better documentation and better templates which are going to be key. The AMA has said over and over that billing [E/Ms] strictly by time is not going to get the physicians appropriate reimbursement,” Bucknam says. “Good documentation of the complexity of decision-making will typically net higher codes and higher billing and reimbursement. However, most of my physicians have not followed that. Time is just so much easier to document.”

MDM a Must for ED Codes

For ED coders, reporting based on MDM is the only way to go with the new ED E/M codes, which read:

• 99281 (E mergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional)
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making)
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making)
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making)
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making)

Because these descriptors focus solely on MDM, there is a renewed focus on MDM for 99281-99285 as well. Now, MDM is not one of three key components you’ll consider when coding an ED E/M; it’s the only component.

According to Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, New Jersey, providers should be doing whatever possible to come to the most accurate MDM level for each claim. To that end, she says practices should consider:

• “Updating their EMR [electronic medical record] templates to capture accurate coding of medical necessity to choose E/M code levels;
• “Educating providers to learn to code E/M services based on medical necessity rather than time;
• “Ensuring billing personnel accurately code what is documented by the provider;
• “Monitoring denials to ensure services are accurately coded; and
• “Getting providers up to date on the new CF.”

“In addition to education on the new AMA CPT^® E/M changes, practices should review other areas of revenue opportunities such as telehealth and behavioral health coverage expansion,” recommends Falbo.

However, even these proactive measures won’t change the fact that 2023 looks to be a lean year. “I think there is better reimbursement to be obtained with the new rules for coding E/Ms, but that won’t make up for all of the loss,” says Bucknam. “Surgeons, for example, who make most of their revenue from procedures will not be able to improve their reimbursement with better documentation. I don’t think there is an easy solution to this problem.”

Practice managers are going to have to look closely at what they bill and how they are reimbursed to try to offset these losses, according to Bucknam. “Some services or supplies that may not have been separately billed in the past are going to have to be billed, and services and supplies that are not covered by insurance will have to be billed at a higher rate to make up the lost revenue.”