ED Coding and Reimbursement Alert

Plus: CMS proposes extending ED telehealth services through 2023.

ED providers could see continued opportunities for reporting telehealth thanks to details in the proposed Medicare Physician Fee Schedule (MPFS), but the overall takeaway from the document could mean lower pay for all Medicare providers.

Background: On July 21, CMS issued its Calendar Year (CY) 2022 MPFS proposed rule. Not as sparse as last year’s 1,350-page document, the 2022 proposal — at 1,747 pages — is chock full of surprises. Highlights include new information about split/shared critical care visits, a possible extension of ED telehealth services, and potential cuts to the conversion factor.

Check out a few important details featured in the proposal.

1. Telehealth Could Continue for ED Codes

The Medicare telehealth expansion has been a real benefit to many emergency departments, but there’s been some confusion about whether the ED E/M codes, critical care codes, and observation codes would remain on the approved telehealth list. Currently, these codes are only billable via telehealth for the rest of the year following the expiration of the public health emergency (PHE).

The proposed rule for 2022 could change that, recommending that these codes would remain on the list of approved telehealth services through December 31, 2023. If approved, CMS aims to analyze data during that period to evaluate the benefits of providing these services via telehealth before deciding whether they could potentially be added to the permanent list of approved telehealth services.

2. Split/Shared Visits May Enter ED

As most ED coders are aware, time is not a factor in determining E/M levels in the ED, other than when billing for critical care services (99291-+99292), which are inherently reported based on time spent.

However, the 2022 proposal includes changes to the existing split/shared visit policies for E/M services, critical care, and teaching physician services. In essence, CMS is suggesting that it may allow critical care to be split between a physician and a non-physician practitioner who are part of the same group, if the physician performs a substantive part of the service.

As part of the proposal, CMS is also requesting comments on which qualifying activities should be used to determine the billing provider for a shared 9928x ED E/M service. Of note, since time is not a factor in the ED (since it’s hard to measure in the chaotic ED environment), medical decision making may be the yardstick that determines whether a substantive portion of the qualifying care was provided by a physician or APP,

3. Expect Lower Conversion Factor

In one of the more alarming CY 2022 proposals, CMS aims to cut the conversion factor (CF) significantly. As you may recall, this was on the agenda for 2021 originally, but Congress allowed for those cuts to be postponed after passing the Consolidated Appropriations Act. However, that temporary adjustment is expected to expire on Dec. 31, 2021.

Therefore, unless Congress acts again, the conversion factor will drop from the current rate of $34.89 to a new rate of $33.58, representing a 3.9 percent decrease.

Public outcry: As expected, industry organizations are rattled by the major CF dip, especially in the midst of new COVID-19 spikes. The American Medical Association (AMA) and American College of Emergency Physicians (ACEP) urged Congress to take action, writing an open letter to congressional leaders.

“All this financial uncertainty comes at a time when physician practices are still recovering from the financial impact of the COVID-19 public health emergency, including continued infection control protocols that, while necessary, have increased the costs of providing care,” AMA CEO James L. Madara, M.D. said in the July 21 letter. “The combination of all these policies would be challenging to endure in normal times. Yet, physician practices continue to be stretched to their limits clinically, emotionally, and financially as the pandemic persists well beyond 15 months.”

Madara went on to say that the Medicare cuts could impact patient access to care, in addition to damaging physician pay. “Adjusted for inflation in practice costs, Medicare physician payment actually declined 22 percent from 2001 to 2020, or by 1.3 percent per year on average,” he said.

4. Consider Commenting Before Deadline

CMS is accepting comments on the proposal through September 13, and the finalized rule is expected to be issued later this year before going into effect on January 1, 2022.

Resource: Review the PFS proposals at https://public-inspection.federalregister.gov/2021-14973.pdf.