Inpatient Facility Coding & Compliance Alert

 Tip: Pay special attention to PQRS, telehealth updates.

Medicare coding changes for 2013 include several items of special interest to ED coders -- namely changes to ED specific Physician Quality Reporting System (PQRS) measures, telehealth coding expansions, and a final answer on where ED physicians stand on getting additional Medicaid pay. If you code for the ED physicians at your facility, here’s what you need to know about implementing the changes without causing too many bumps in your reimbursement road.

Forget About Frequently Reported ED PQRS Measures

CMS plans to retain the 12-month calendar year reporting period for the PQRS program in 2013 and beyond. The incentive payment for 2013 will remain 0.5 percent. The 2013 reporting period data will be used to determine both the 2013 incentive payment (0.5 percent) and the 2015 payment adjustment (-1.5 percent).

Successful reporting requirements for the program are proposed to remain as they were in 2012, requiring that participants report a minimum of three individual measures or group measure via claims based reporting on 50 percent or more of all eligible Medicare patients, or report a minimum of three individual measures or 1 group measure via registry reporting on 80 percent or more of all eligible Medicare patients, says

The plan eliminates the following measures:

• 57 -- Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation
• 58 -- Community-Acquired Pneumonia (CAP): Assessment of Mental Status
• 92 -- Acute Otitis Externa (AOE): Pain Assessment
• 253 -- Pregnancy Test for Female Abdominal Pain Patients

Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, MA.

Big dent: Losing measures 57 and 58 will impact a significant percentage of those groups who are successfully participating in PQRS. The above pneumonia measures are widely used by emergency physicians to satisfy the PQRS reporting requirement, warns Granovsky.

Bright side: However, two of the pneumonia measures 56 (Community-Acquired Pneumonia [CAP]: Vital Signs) and 59 (Community-Acquired Pneumonia [CAP]: Empiric Antibiotic) do remain, as well as Measure 28 (Aspirin at Arrival for Acute Myocardial Infarction) and Measure 54 (12 lead ECG Performed for Non Traumatic Chest Pain) and Measure 55 (EKG for syncope) the other typically utilized ED PQRS measures will remain in use.

 Don’t Miss Additional Telehealth Uses 

Telehealth services are being expanded to include an annual alcohol misuse screening, brief behavioral counseling for alcohol misuse, annual face-to-face intensive behavioral therapy for cardiovascular disease, annual depression screening, behavioral counseling for obesity, and semi-annual high intensity behavioral counseling to prevent sexually transmitted infections, says Granovsky.

Take note: Payment is only on the facility side, not for individual physicians.

The Medicare payment amount for emergency department or initial inpatient telehealth consultations furnished via an interactive telecommunications system is equal to the current fee schedule amount applicable to initial hospital care provided by a physician or practitioner. The Medicare payment for code Q3014, the telehealth originating site facility fee for 2013, should be $24.43. There are no RVUs listed in the physician fee schedule for the service, says Granovsky.

 Don’t Count on Medicare Rates for Medicaid  

One of the most anticipated decisions for 2013 was the concept of paying Medicare rates for Medicaid patients of primary care providers to encourage their participation in the Affordable Care Act (ACA) driven expansion of the Medicaid rolls. The services to receive increased Medicaid payment are those billed with E/M codes 99201-99499 -- including those not reimbursed by Medicare -- and vaccine administration codes 90460-90461 and 90471-90474. The proposed funding is currently limited to a two-year span.

How it works: The actual distribution of the federal funds to boost Medicaid rates to primary care practitioners will be left up to the individual states. This will be important to watch because the difference between Medicaid and Medicare rates varies across each state, with the national average of roughly 60 cents for every dollar Medicare pays. In some states, the Medicaid payment would nearly double, adds Granovsky.

The question: So, can emergency physicians be considered primary care to get the increased payment?

The answer: Unfortunately, CMS clarified that it did not intend to allow anyone Board Certified in Emergency Medicine (or any other specialty not identified) to self-certify into the program. Any physician that is Board Certified in a specialty designation that is not identified in the regulation (Family Physicians, General Internal Medicine, and Pediatrics) will not be allowed to claim the increased payments.

 Keep Watching for Value Based Payment Modifier 

This issue is still evolving, but CMS states in the 2013 final rule that the value-based payment modifier won’t likely kick in until 2017 unless your practice employs 100 or more providers.

What it does: The modifier will adjust all physicians’ payments, depending on how they improve care and reduce costs compared with others in their region and specialty. CMS originally proposed applying the modifier, which would adjust Medicare rates by plus or minus 1 percent, in 2015 to groups with 25 or more eligible providers and then to practices of all sizes in 2017.

PQRS scores are a dominant component for the detail that has been proposed. If you satisfactorily report PQRS for 2013 and 2014, your VBP modifier will be 0.0 percent. If you do not satisfactorily report under PQRS your VBP will be as much as -1.0 percent, plus an additional -1.5 percent as a PQRS program specific penalty for a total of -2.5 percent.

There will be an efficiency (resource use) component of the VBP modifier as well and it remains less well defined for ED physicians. This provision will likely see some additional refinement. Do not lose sight that the reporting in 2013 and 2014 will be the basis for your assigned payment modifier in 2015, warns Granovsky.