EM Coding Alert

Move forward with ICD-10 plans for this fall, too. 

Things looked bleak as April began and Congress failed to take action to override the 21 percent Medicare pay cut. But by mid-month, practices rejoiced as the President finalized legislation aimed to prevent physician pay cuts.  

Background: The House passed the Medicare Access and CHIP Reauthorization Act (MACRA), the Senate failed to vote on the bill before departing for a two-week recess on March 27.

“Their failure to act leaves physicians facing a devastating 21 percent cut in Medicare reimbursements when the current Sustainable Growth Rate (SGR) payment patch expires on March 31,” said Robert M. Wah, MD, president of the AMA, in a March 27 statement.

Good news: Because electronic claims take at least 14 days to process and paper claims take at least 29 days, the cut would have started affecting your payments on April 15. However, on April 14, just a few hours before the midnight deadline, the Senate voted 92-8 to pass the bill to get rid of the SGR formula. The President signed the bill into law on April 16. 

“No more will we be kicking the can down the road with another temporary ‘fix’ to the SGR rate,” said U.S. Senator Ben Cardin (D-Md.), a member of the Senate Finance Subcommittee on Health Care, in a statement.

“Passage of this historic legislation finally brings an end to an era of uncertainty for Medicare beneficiaries and their physicians — facilitating the implementation of innovative care models that will improve care quality and lower costs,” James L. Madara, MD, AMA Executive Vice President and CEO, said in a statement.

Watch For a Boost Next Year

MACRA eliminates the SGR formula for Medicare physician payment once and for all. Congress has passed 17 SGR “patches” since 2002, which has made both legislators and physicians wary about simply moving the problem forward yet again.

The bill gives 0.5 percent annual boosts to Medicare pay for five years, after which practitioners would get bonuses based on quality of care rather than the number of procedures they administer. The cost of the plan would reportedly amount to about $200 billion over the next decade, and some of that cost could be passed on to higher-earning Medicare beneficiaries.

“As written, we would see annual physician payment updates of 0.5 percent from 2015 through 2019 and zero percent updates from 2020 through 2015,” explains Michael A Granovsky MD, FACEP, CPC, President of LogixHealth a national ED coding and billing company. “Starting in 2026, we would see two conversion factors, one that applies to providers that participate in advanced payment models such as an ACO, with a 0.75 percent annual update. A second conversion factor with a 0.25 percent yearly increase would apply to providers who do not participate in advance payment models,” he adds.

Don’t Know the Other MACRA Details

The bill calls for consolidation of three current incentive programs, PQRS, HER meaningful use and the value based modifier program into the new Merit-Based Incentive Payment System (MIPS).

MIPS will assess performance of eligible professionals in four categories (quality, resource use, meaningful use of EHRs and clinical practice) and provide a payment adjustment, which could be positive or negative depending on your composite performance score. 

The current penalties in play for meaningful use, PQRS and Value based modifier, would be replaced by MIPS which rapidly escalates form 4 percent in 2019 to 9 percent in 2022, Granovsky explains.

Additionally: MACRA contains other provisions important to emergency medicine reimbursement, including:

• Extension of work Geographic Practice Cost Index (GPCI) floor: This provision extends the existing 1.0 floor on the “physician work” cost index work component of physician fees in areas where labor cost is lower than the national average until Jan. 1, 2018. 

• Two-year extension of CHIP: The Children’s Health insurance program (CHIP) covers more than 8 million children and pregnant women in families that earn income above Medicaid eligibility levels. While the CHIP program is authorized through 2019, no new funding is available after fiscal year 2015. This provision preserves and extends CHIP, funding the program through fiscal year 2017. 

• Income-related premium adjustment for Parts B and D: This provision increased means testing for the portion of the Medicare Part B premium that a beneficiary pays based on the beneficiary’s income. Beginning in 2018, it would increase the percentage that Medicare beneficiaries with modified adjusted gross income (MAGI) between $133,501 and $160,000 ($267,001-$320,000 for a couple) from 50 percent to 65 percent. Beneficiaries that earn $160,001 and above ($320,001 and above for a couple) would pay 80 percent. This provision would also apply to Part D premiums, meaning that beneficiaries who have income above the set thresholds are assessed an income-related monthly adjustment amount in addition the base Part D monthly premium. 

• Delay of the two-midnight rule: Current CMS regulation requires a patient stay of two-midnights in a hospital to qualify for inpatient status in most instances. Stays that are less than that will be paid as an outpatient visit such as observation. This provision allows CMS to continue use of the Medicare Administrative Contractor (MAC) “probe and educate” program to assess provider understanding and compliance with the “two-midnight rule,” on a pre-payment basis, through Sept. 30, 2015.

• Delay in elimination of the global surgical packages: This provision reverses the CMS 2015 final rule decision to eliminate the bundled payment for surgical services that span a 10- and 90-day period. It requires CMS to periodically collect information on the services that surgeons furnish during these global periods beginning not later than 2017 and use that information to ensure that the bundled payment amounts for surgical services are accurate. The Secretary of HHS has the authority to delay a portion of payment for services with a 10- and 90-day global period to incentivize reporting of information. The Secretary can stop the collection of information from surgeons if the needed information can be obtained through other mechanisms, such as clinical data registries and electronic medical records.

Know the ICD-10 News, Too

Last year, the House of Representatives included a last-minute addition into the SGR legislation, which delayed the ICD-10 implementation deadline for another 12 months, to October 1 of this year. The postponement was the third delay in six years. Industry experts were concerned the same thing would happen again this year. 

Be ready: There is no further ICD-10 delay stipulations in the legislation this year, which means your practice needs to be ready for the Oct. 1, 2015 implementation deadline.