The 2019 Medicare Physician Fee Schedule was released Nov. 1, 2018, with generally good news for emergency medicine. As anticipated, there were minimal changes to the emergency department evaluation and management (E/M) codes, critical care, and observation service values for 2019. Table 94 of the Final Rule lists the estimated impact by specialty based on changes to the work, practice expense, and professional liability insurance relative value units (RVUs) for 2019. Many of the specialties listed, including emergency medicine, had an estimated change of 0 percent in overall revenue. There were few winners, such as podiatry with a 2 percent increase. The losers in 2019 are extensive, including diagnostic testing facilities with a 5 percent decrease, as well as independent laboratory, pathology, nuclear medicine, optometry, and infectious disease with 1 percent decreases. Many of the specialties receiving decreases have had their revenues go down several years in a row, while emergency medicine has been stable or slightly up.

Emergency Medicine RVUs Stable

The 2018 Physician Final Rule highlighted concerns that emergency department E/M services may be undervalued. As a result, ACEP undertook a vigorous survey process related to the emergency department E/M codes (99281–99285) that make up 83 percent of our RVUs. The survey results were robust and presented for valuation by the Relative Value Scale Update Committee (RUC). Although the RUC’s deliberations remain confidential, we are able to share that the ACEP RUC advisers presented compelling arguments demonstrating the increase in the acuity of our patients, and the Centers for Medicare & Medicaid Services (CMS) will consider the RUC’s recommendations as part of the 2020 Medicare Physician Fee Schedule (see “What’s in the 2019 Medicare Physician Fee Schedule Proposed Rule?” September 2018). The updated RVUs, based on the recent survey and presentation, will likely be published for use in 2020. For 2019, in the interim, the emergency department RVUs for 99281–99285 remain exactly the same as last year (see Table 1). Only critical care will change for 2019 with a very small decrease at the hundredth of an RVU level.

(click for larger image) Table 1: 2018 and 2019 Emergency Medicine RVUs
RVU=relative value unit; PE=practice expense; PLI=professional liability insurance

Conversion Factor (Medicare Payment Per RVU) Increases

The Bipartisan Budget Act of 2018 mandated a 0.25 percent increase to the conversion factor for 2019. A negative budget adjustment factor of –0.14 percent impacted the 2019 conversion factor to offset overall increases in RVUs relative to 2018. The net impact is an increase of about $0.04 to the 2019 conversion factor, as shown in Table 92 from the Final Rule, with a published conversion factor of $36.0391 (see Table 2).

(click for larger image) Table 2: Calculation of the Proposed CY 2019 Physician Fee Schedule Conversion Facto

The small increase for 2019 is consistent with the trend of the final conversion factor value sticking to a fairly tight range, though it has been some time since we have broken through the $36 mark (see Figure 1).

Documentation Guideline Reform Not for ED Codes

CMS has expressed a desire to move away from the “bean counting” history and exam requirements of the 1995 documentation guidelines and place a greater emphasis on documented time and medical decision making, a position that has been well supported by the provider community:

“Stakeholders have long maintained that all of the E/M documentation guidelines are administratively burdensome and outdated with respect to the practice of medicine. Stakeholders have told CMS that they believe the guidelines are too complex, ambiguous, fail to meaningfully distinguish differences among code levels, and are not updated for changes in technology, especially electronic health record (EHR) use.” —2019 Medicare Physician Fee Schedule Final Rule

CMS has opted for a measured approach to updating the documentation guidelines. While there will be no changes to the emergency department code documentation requirements, the office visit codes will undergo a major restructuring in two years (2021). For 2019 and 2020, CMS will continue the existing documentation requirements. Starting in 2021, CMS will create a single code for new and established E/M office/outpatient visit levels 2 through 4 and keep level 5 separate.

Teaching Physician Documentation Guidelines Updated

CMS has worked to decrease the potential for duplicative documentation in academic medical settings.

“The purpose of these revisions to the regulations is to eliminate potentially duplicative requirements for notations that may have previously been included in the medical records by residents or other members of the medical team. The teaching physician continues to be responsible for reviewing and verifying the accuracy of notations previously included by residents and members of the medical team, along with further documenting the medical record if the notations previously provided did not accurately demonstrate the teaching physician’s involvement in an E/M service.” —2019 Medicare Physician Fee Schedule Final Rule

However, unlike prior Teaching Physician guidance (Medicare Transmittal 1780 and 811), which provided examples of acceptable and unacceptable documentation, the 2019 Physician Final Rule does not provide such examples. Absent specific examples, ACEP will be asking CMS for further clarity.

Telemedicine is Gaining Acceptance in 2019, But Not Yet for ED Use

In an effort to expand the use of telehealth in Medicare, CMS will begin to pay separately for two newly defined physician services furnished using communication technology:

1. Brief Communication Technology-Based Service: This service will cover a “virtual check-in” by a patient via telephone or other telecommunications device to decidewhether an office visit or other service is needed.
2. Remote Evaluation of Recorded Video and/or Images Submitted by the Patient: This service will allow practitioners to be separately paid for reviewing a patient-transmitted photo or video information (such as by text message) to assess whether a visit is needed.

However, each of these codes are intended for use only with established patients, which will limit their use in the typical emergency department setting.

Combatting the Opioid Crisis

Importantly, beginning in July 2019, a patient’s home will be eligible to be the originating site for telehealth services for opioid and substance abuse disorder treatment or co-occurring mental health disorders, which could help reduce the opioid crisis and related emergency department visits.

Few CPT Changes for Emergency Medicine in 2019

There were no significant changes in the E/M code section of CPT and just the usual updating of the vaccine codes in the medicine section relating to tweaks of the composition or dosage information, including 18 changes in codes for influenza vaccines.

Changes for Emergency Medicine in ICD-10 Diagnosis Coding for 2019 Unlike CPT code changes that occur on the calendar year, ICD-10 code changes are updated and effective in October. Emergency department relevant codes added, deleted, or revised include the areas of mental and behavioral presentations, cerebral infarction, and appendicitis. In keeping with the times, there are two new codes related to cannabis use:

• F12.23, cannabis dependence with withdrawal
• F12.93, cannabis use with withdrawal

Code F12.23, cannabis dependence with withdrawal, was created to distinguish cannabis withdrawal syndrome in a patient with cannabis dependence. Code F12.93, cannabis use, unspecified with withdrawal, was created for cases of physiological withdrawal from cannabis occurring in a person who is using cannabis regularly in contexts that are not specifically defined as cannabis dependence.

Example: A 26-year-old male presents to the emergency department with tingling in his hands and feet. He has a history of generalized anxiety disorder and has been smoking cannabis on a daily basis for the last 10 months to help with his anxiety. The patient abruptly stopped smoking cannabis three days ago and, in addition to the tingling, also complains of a cough. Physical exam was reassuring and a chest X-ray was negative. Various approaches to anxiety treatment, including counseling and pharmacotherapy, were discussed. The patient will follow up with his primary care physician and understands reasons to return to the emergency department. The final diagnoses for the visit includes cannabis use with withdrawal F12.93.

Dr. Granovsky is the president of Logix Health, an emergency department coding and billing company, and serves as the course director of ACEP’s coding and reimbursement courses.

Mr. McKenzie is reimbursement director for ACEP.