Medicare Compliance & Reimbursement

Actual distribution of the federal funds to boost Medicaid rates left up to the individual states.

The 2013 Medicare Fee Schedule released Nov. 6 has brought a mixed bag for emergency departments. Sustainable Growth rate (SGR) driven reduction in the Medicare conversion factor could lead to a drop by 26.5 percent to $25.0008, even though the RVU rates have stayed flat. Get the expert analysis of the most ED-relevant issues that will impact your group payments next year.

The final rule includes Tables 134 and 135 that offer estimates on the impact of the 2013 physician fee schedule provisions by specialty.

Caveat: Both by RVU changes and the impact of various policies (PPIS, MPPR utilization, TCM) the estimated impact for emergency medicine is zero percent for 2013. However, those estimates do not take the impending SGR cut of 26.5 percent into consideration.

The work RVUs for ED E/M and observation codes were unchanged, but we did see some small fluctuations in the practice expense RVUs. The net impact of those changes, typically only at the hundredth of an RVU level, are minimal says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, MA.

Brace for GPCI Artificial Floor Provision Expiration

If your ED is in Alaska or the frontier states (MT, ND, SDA, NV, and WY), you’ll continue to enjoy a permanent minimum work Geographic Practice Cost Index (GPCI) threshold, but the expiration of the statutory 1.0 work GPCI floor is set to expire on Dec. 31, 2012. The impact of this change on several geographic regions can be significant, says Granovsky. Historically, the GPCI floor provision has been extended as part of the annual SGR patch legislation. We will have to wait and see how Congress reacts this year, he adds.

Medicare Rates For Medicaid Unlikely for ED

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 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.

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.

Must have certification: So, can emergency physicians be considered primary care to get the increased payment? Unfortunately, CMS has 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, says Granovsky.

Factor in ED Telehealth Consults

There is some good news in the final rule. Section 415.65(a) (1) (i) of the rule was changed to include ED telehealth consults, correcting an oversight in the previous version.

The catch: Payment is only on the facility side. 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.

Stay Tuned 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.