ED Coding and Reimbursement Alert

Could you end up with more money for your ED visits?

CMS has released its 2018 proposed Medicare Physician Fee Schedule, which recommends updates to the Part B payment policy. The proposals could be significant for emergency departments, since some of the biggest revisions could bring more pay to ED visits and could change the E/M documentation requirements.

Potential ED Pay Boosts

On the plus side, CMS appears to be open to boosting payment for emergency department visits. Page 107 of the Fee Schedule proposal states, “We have received information suggesting that the work RVUs for emergency department visits may not appropriately reflect the full resources involved in furnishing these services. Specifically, stakeholders have expressed concerns that the work RVUs for these services have been undervalued given the increased acuity of the patient population and the heterogeneity of the sites, such as freestanding and off-campus emergency departments, where emergency department visits are furnished.”

In other words, CMS is considering compensating EDs more for these visits to mitigate the growing costs of treating the increasingly complex patient population presenting to emergency departments nationwide. “We are, therefore, seeking comment on whether CPT^® codes 99281-99385 (Emergency department visit for the evaluation and management of a patient…) should be reviewed under the misvalued code initiative,” the proposal says.

“Remember that comments to the proposed rule will be considered and addressed in the CMS final rule for the 2018 Medicare Physician Fee Schedule,” says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford Massachusetts. “If the proposal to reconsider the value of the ED E/M codes is in that rule, the RBRVS Update Committee or RUC will ask interested parties to survey the codes and provide compelling evidence for any changes in the current value.”

Potential E/M Documentation Changes

The proposed rule also indicates that CMS is looking at updating the E/M code requirements for the first time in decades. “We are specifically seeking comment on how we might focus on initial changes to the guidelines for the history and physical exam because we believe documentation for these elements may be more significantly outdated, and that differences in medical decision-making (MDM) are likely the most important factors in distinctions between visits of different levels,” CMS says on page 377 of the proposal.

CMS is not only suggesting that it might lean more heavily on MDM when selecting an E/M level, but even appears to be considering eliminating history and physical exam documentation requirements entirely. “We are also specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels,” the proposal says. “We believe medical decision-making and time are the more significant factors in distinguishing visit levels, and that the need for extended histories and exams is being replaced by population based screening and intervention, at least for some specialties.”

Although some practices are cheering the lower documentation burden that this could create, others are questioning why CMS would loosen the requirements for an area of coding that already has challenges. “Removing the history and physical (H&P) component from coding guidelines is like having a tree with no ‘roots,’” suggests Vinod Gidwani, president of full-service revenue cycle firm Currence, based in Skokie, Illinois. “The H&P determines the level of medical decision-making as well as the time component. Removing the H&P is like determining the MDM and time components in a vacuum,” Gidwani says.

No matter where you stand on this discuss, CMS wants to hear from you. “We are seeking comment on whether clinicians and other stakeholders believe removing the documentation requirements for the history and physical exam would be a good approach,” the agency says in the proposal.

“Although we appreciate CMS wanting to reduce the documentation burden, we need to think our comments through carefully,” Granovsky says. “CPT^® is clear that there is no time component to the ED E/M codes. If that leaves onlyMDM as the determining factor of the visit level, we would have to be sure payers adhere to the accepted descriptions of MDM levels. The emergency medicine community is confronting numerous denials based on payers’ creative interpretations of what is included in accepted guidelines and standards.”

Resource: To read the proposed fee schedule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14639.pdf.