Emergency Department 2018 Physician Update

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Daniel Walker
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Emergency Department Physician Update CMS Final Rule MACRA Legislation and the Elimination of the Sustainable Growth Rate Formula Conversion Factor Merit-Based Incentive

1 Emergency Department Physician Update CMS Final Rule MACRA Legislation and the Elimination of the Sustainable Growth Rate Formula Conversion Factor Merit-Based Incentive Payment System (MIPS) Geographic Practice Cost Index Update RVUs for ED E/M Services RVUs for Observation Potentially Misvalued Codes Documentation Guidelines: Changes Coming Soon?

2 CMS Final Rule On November 2,, Medicare released the Physician Fee Schedule final rule. The final rule governs payment rates, as well as other critical reimbursement issues, for dates of service beginning on January 1,. The rule, which is published in the November 15, Federal Register can be found on the LogixHealth website, MACRA Legislation and the Elimination of the Sustainable Growth Rate Formula The rule is not governed by the Sustainable Growth Rate (SGR) formula, which had mandated continuing annual cuts to physician payments, resulting in year-after-year eleventh-hour congressional rescues with short-term fixes. Instead, with the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), represents the second year of a stabilized conversion factor. In addition to stabilizing the conversion factor, MACRA also provided for sweeping payment reforms combining the quality programs of PQRS, the Value Modifier process, and Meaningful Use into a single CMS quality payment program: Merit-Based Incentive Payment System (MIPS). Conversion Factor At the conclusion of, the Medicare conversion factor (the amount Medicare pays per RVU) was set at $ MACRA provides for annual conversion factor payment increases of 0.5% through With the application of the RVU budget neutrality adjustment and the target recapture amount related to misvalued procedures, the 0.5% update was decreased meaningfully. As a result, the final rule published a conversion factor of $ , representing a roughly $0.11 increase. Merit-Based Incentive Payment System (MIPS) The Merit-Based Incentive Payment System (MIPS) represents a payment mechanism that provides for annual reimbursement adjustments related to quality program requirements impacting 2020 payments based on reporting in four categories: Quality Resource Use Clinical Practice Improvement Activities Meaningful Use of an Electronic Health Record System For the performance year (impacting 2020 payments), the four MIPS categories will be simplified for most emergency physicians. The final rule assigned the Resource Use category a weighting of 10% for (likely increasing to 30% for 2019) in what Medicare termed a second transition year. In addition, if a provider delivers greater than 75% of their Medicare services in an emergency department they are excused from the Meaningful Use EHR component of MIPs. The consolidated program is then reweighted in to 75% Quality (the old PQRS program), 10% Resource Use, and 15% Improvement Activities. Unlike the SGR s annual changes, the MIPS system adjusts physician payments based on performance. MIPS does not have an aggregate spending target, which is what previously created the need for annual congressional patches to prevent the mandated SGR cuts. The MIPs program starts at +/-4% and increases by 2022 (based on 2020 performance) to +/-9%. Evolution of the Federal Quality Payment Program Base 0.5% 0.5% 0.5% 0.5% Base conversion factor update of 0.0 each year 0.25% Continues under EHR current law Continues under PQRS +/-4% MPS +/-5% MPS current law +/-7% ( ( +/-9% MPS MPS Continues under performance) performance) VM current law MIPS N/A 1

3 Geographic Practice Cost Index Update The geographic practice cost index (GPCI) is used by CMS to modify the RVU values based on regional differences relating to cost of living, malpractice, and practice cost/expense. The GPCI values allow Medicare to adjust reimbursement rates to take into account regional and practice-specific factors. Some states have a permanently fixed work GPCI, including Alaska at 1.5 and the frontier states at 1.0 (Montana, Nevada, North Dakota, South Dakota, and Wyoming). Other states are subject to a work RVU GPCI that ranges from However in past years, Congress passed single-year legislation, setting a GPCI work floor of 1.0 that then expired at the end of the year. The work GPCIs reflect the MACRA extension of the 1.0 GPCI work floor for services provided through December 31,. Congress is likely to extend the current GPCI floor through an adjunctive regulatory process. Final Rule Conversion Factor Calculation January 1, through December 31, Conversion Factor Conversion Factor in effect in CY $ Update Factor 0.5% (1.0050) CY RVU Budget Neutrality Adjustment -0.10% (0.9990) CY Target Recapture Amount 0.09% (0.9991) CY Conversion Factor $ For the most up-to-date information, visit us online at logixhealth.com. 2

4 RVUs for ED E/M Services Each year, updated RVUs for physician services are published in the final rule. For, the work RVUs for emergency medicine services remain unchanged. The total RVUs associated with ED E/M services are essentially unchanged as well. The CMS specialty-specific impact analysis states that emergency medicine will experience a 0% update in overall Medicare reimbursement for. The published 0% increase for emergency medicine as a specialty contains moderate rounding. The RVUs for our codes are essentially unchanged and the conversion factor has been increased by roughly a quarter of a percent. However, CMS has recommended that the Relative Value Update Committee (RUC) survey and potentially revalue the work RVUs associated with the codes citing that they are potentially undervalued. This survey will take place in and updated work RVUs, if any, would likely be in effect in ED E/M RVUs , Code PE RVUs PE RVUs PLI RVUs PLI RVUs ED E/M to Be Revalued The Physician final rule highlighted concerns that the ED E/M services may be undervalued. We received information suggesting that the work RVUs for emergency department visits did not appropriately reflect the full resources involved in furnishing these services. Specifically, stakeholders expressed concerns that the work RVUs for these services have been undervalued given the increased acuity of the patient population and the heterogeneity of the sites, such as freestanding and off-campus emergency departments, where emergency department visits are furnished. Therefore, we sought comment on whether CPT codes (Emergency department visits for the evaluation and management of a patient) should be reviewed under the misvalued code initiative. Physician final rule, page 165/1250 We agree with the majority of commenters that these services may be potentially misvalued given the increased acuity of the patient population and the heterogeneity of the sites where emergency department visits are furnished. As a result, we look forward to reviewing the RUC s recommendations regarding the appropriate valuation of these services for our consideration in future notice and comment rulemaking. Physician final rule, page 166/1250 3

5 RVUs for Observation Observation services were also revalued for, resulting in some small adjustments. Same-Day Observation CPT Code PE RVUs PE RVUs Multi-Day Observation Services (Initial Day) CPT Code Multi-Day Observation Services (Discharge Day) CPT Code Subsequent Observation Services Subsequent observation services remained relatively stable from -. CPT Code Critical Care Services Critical care services were also revalued as part of the final rule and received small changes. CPT Code

6 Potentially Misvalued Codes In the 2012 Physician Fee Schedule final rule, CMS finalized a proposal to consolidate into one annual process the reviews of: Practice expense RVUs Potentially misvalued codes ED Relevant Potentially Misvalued Services HCPCS Long Descriptor Application of rigid total contact leg cast Control nasal hemorrhage, anterior, simple Control nasal hemorrhage, anterior, complex Control nasal hemorrhage, posterior Tracheostomy, emergency procedure Tracheostomy, emergency procedure; cricothyroid membrane Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older Arterial catheterization or cannulation for sampling, monitoring Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging Injection, anesthetic agent; suprascapular nerve Radiologic examination, ribs multiple image(s) and view(s) Radiologic examination, wrist/hand/finger multiple image(s) and view(s) Radiologic examination, abdomen; complete Radiologic examination, abdomen; multiple view(s) 5

7 Documentation Guidelines: Changes Coming Soon? In the Physician Fee Schedule proposed rule CMS sought comments regarding the 1995 and 1997 Documentation Guidelines and their current relevance to clinical practice. The commentary and response was robust and CMS devoted substantial space in the Physician final rule to review an assessment of the value of the current Documentation Guidelines. In fact, CMS plainly stated the Documentation Guidelines may be outdated: Stakeholders have long maintained that both the 1995 and 1997 guidelines are administratively burdensome and outdated with respect to the practice of medicine, stating that they are too complex, ambiguous, and that they fail to distinguish meaningful differences among code levels. In general, we agree that there may be unnecessary burden with these guidelines and that they are potentially outdated, and believe this is especially true for the requirements for the history and the physical exam. Physician final rule, page 495/1250 The Documentation Guidelines have not kept pace with technology: The guidelines have not been updated to account for significant changes in technology, especially electronic health record (EHR) use, which presents challenges for data and program integrity and potential upcoding given the frequently automated selection of code level. Physician final rule, page 495/1250 CMS may be interested in updated Guidelines focusing on Medical Decision Making: We stated our belief that in the near term, it may be possible to eliminate the current focus on details of history and physical exam, and allow MDM and/or time to serve as the key determinant of E/M visit level. Physician final rule, page 495/1250 Change to the Documentation Guidelines appears to be coming soon: We expect to continue to work on all of these issues with stakeholders in future years though we are immediately focused on revision of the current E/M guidelines in order to reduce unnecessary administrative burden. Physician final rule, page 503/1250 6

Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year 2018

Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year 2018 Date 2017-11-02 Title Contact Final Policy, Payment, and Quality Provisions in the Medicare Physician