Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Changes to the 2018 Medicare Fee Schedule Emergency Physicians Need to Know

2018 Medicare Fee Schedule emergency physicians

The Centers for Medicare and Medicaid Services (CMS) recently finalized the 2018 Medicare Physician Fee Schedule (MPFS) and related policies, generally giving physicians and other eligible providers a .41 percent increase as proposed back in July. However, after applying the geographic practice cost index, emergency physicians in Indiana will actually see a small decrease in fees.

The .41 percent increase reflects the .50 percent update established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by 0.09 percent due to the misvalued code target recapture amount required under the Achieving a Better Life Experience Act of 2014. 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 $35.9996.

Payment rates for individual services are then calculated by locality using the following formula: Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI MP)] x CF. For emergency medicine evaluation and management codes in Indiana, prices for 2018 are as follows (with 2017 included for comparison):

CPT 2017 Fee 2018 Fee
99281 $20.50 $19.88
99282 $39.95 $38.74
99283 $59.81 $57.98
99284 $113.49 $109.97
99285 $167.40 $162.01
99291 $215.68 $209.14

Indiana and Michigan providers can find a complete updated fee schedule on the WPS-GHA 2018 Medicare Physician Fee Schedules (MPFS) page. To see the impact of the E&M payment changes on your Medicare reimbursement, download this Excel worksheet calculator.

Revaluing Emergency Department E/Ms

In addition to change fees, the proposed 2018 MPFS solicited comments about whether work RVUs for emergency department visits “may not appropriately reflect the full resources involved in furnishing these services,” according to CMS. They pointed 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.

After receiving comments from many different stakeholders, CMS responded by saying they “look forward to reviewing the RUC’s recommendations regarding the appropriate valuation of these services for our consideration in future notice and comment rulemaking.”

Quality Reporting

Finally, 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 finalizing their proposals to modify the performance guidelines to better align the past programs with the new MIPS guidelines.

Specifically, CMS is changing 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 finalizing 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 -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.

For more information about the 2018 Medicare Physician Fee Schedule, review the CMS Fact Sheet or the complete Final Rule.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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