Proposed Changes to the Medicare Fee Schedule that Could Affect Emergency Physicians

Emergency physicians may benefit from future changes in Medicare billing policy outlined in the proposed Medicare Physician Fee Schedule released earlier in June. The Centers for Medicare and Medicaid Services (CMS) is asking for comments on two different guidelines that could ease documentation requirements and improve reimbursement for coding and billing evaluation and management (E/M) services in the emergency department.

Revaluing Emergency Department E/Ms

As they currently are assigned, work RVUs for emergency department visits “may not appropriately reflect the full resources involved in furnishing these services,” according to CMS. They point to the increased acuity of emergency patients and the variety of ED sites (freestanding, off-campus, on-campus, etc.) as evidence that CPT codes 99281-99285 may be misvalued.

While CMS is not currently adjusting the work RVUs, they are accepting comments from stakeholders as to whether they should be adjusted in the future.

Documentation Guidelines

In the same proposed rule, CMS also is rethinking documentation guidelines for billing all E/M codes. Currently, physicians must choose either the 1995 or 1997 guidelines which specify how much information must be documented to support the level of service in each of three categories:

History of Present Illness (HPI or History);
Physical Examination (Exam); and
Medical Decision Making (MDM).

Agreeing with stakeholders, CMS has acknowledged that “there may be unnecessary burden with these guidelines and that they are potentially outdated, … especially … for the requirements for the history and the physical exam.” As well, CMS said the guidelines do not reflect the significant changes in technology over recent years, including electronic health record (EHR) use, “which presents challenges for data and program integrity and potential upcoding given the frequently automated selection of code level.”

CMS is floating a range of possible changes to the history and physical exam guidelines, to “both reduce clinical burden and improve documentation in a way that would be more effective in clinical workflows and care coordination.” Specifically, they are seeking comments on the following options:

whether to remove documentation requirements for the history and physical exam for all E/M visits at all levels and instead allow MDM and/or time to serve as the key determinant, since “medical decision-making and time are the more significant factors in distinguishing visit levels,” and “the need for extended histories and exams is being replaced by population based screening and intervention, at least for some specialties.”
whether to simply require documentation that is “generally consistent with complexity of MDM” and no longer include “detailed specifications for what must be performed and documented for the history and physical exam.”
whether CMS should leave it largely to the discretion of individual practitioners to what degree they should perform and document the history and physical exam.
how such reforms may differentially affect physicians and practitioners of different specialties, including primary care clinicians, and how to account for such effects.

While CMS currently is considering changes only to history and exam documentation guidelines, they also are receiving comments about future updates to MDM guidelines that would “foster appropriate documentation for patient care commensurate with the level of patient complexity, while avoiding burdensome documentation requirements and/or inappropriate upcoding.”

Aligning Quality Reporting

Two other proposed changes to CMS’s quality reporting programs may also impact emergency physicians in the more immediate future.

While the PQRS and Value Modifier programs have been replaced with the MACRA Quality Payment Program’s Merit-based Incentive Payment System (MIPS), physicians may still experience the impact of the PQRS/Value Modifier penalties in 2018, based on the 2016 reporting year. The data for that final reporting year had to be submitted by March 2017, so physicians can no longer adjust their submissions. However, CMS is proposing to modify the performance guidelines to better align the past programs with the new MIPS guidelines. Specifically, CMS is proposing to change the current PQRS program policy that requires reporting 9 measures across 3 National Quality Strategy domains to require only 6 measures.

Likewise, for the Value Modifier, CMS is proposing the following changes:

reduce the automatic downward payment adjustment for not meeting minimum quality reporting requirements from -4 percent to -2 percent for groups of ten or more clinicians; and from -2 percent to negative -1 percent for physician and non-physician solo practitioners and groups of two to nine clinicians;
hold harmless all physician groups and solo practitioners who met minimum quality reporting requirements from downward payment adjustments for performance under quality-tiering for the last year of the program; and
align maximum upward adjustment amounts to 2 times the adjustment factor for all physician groups and solo practitioners.

2018 Conversion Factor

Finally, the policy change that affects all payments to all providers in all specialities is the updated conversion factor.

For 2018, the overall proposed update to payments under the PFS is .31 percent. This updated conversion factor reflects the .50 percent update established under MACRA, and reduced by .19 percent under the Achieving a Better Life Experience (ABLE) Act of 2014’s misvalued code target recapture amount.

By applying these adjustments, plus the budget neutrality adjustment for changes in RVUs, to the 2017 PFS conversion factor of $35.89, the proposed 2018 PFS conversion factor is $35.99.

For more information about the proposed rule, review CMS’s fact sheet or view the proposed rule in its entirety.

Comments on the above or other issues contained in the rule must be submitted no later than 5 p.m. on September 11, 2017. To submit your comments, refer to file code CMS-1676-P and choose one of the following methods (NOTE: CMS will not accept comments by facsimile (FAX) transmission):

Electronically through www.regulations.gov. Follow the instructions for “submitting a comment.”
By regular mail to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P, P.O. Box 8016, Baltimore, MD 21244-8013.
By express or overnight mail to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
By hand or courier to either of the following addresses: 1.) Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201 (Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) OR 2.) Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850 (If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.).