The Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (PFS) Final Rule on Oct. 31, 2014. It addresses changes to the physician fee schedule as well as other important Medicare Part B payment policies. The rule became effective Jan. 1, 2015, and was published in the Nov. 25, 2014, Federal Register.

The 2015 Medicare Conversion Factor

At the conclusion of 2014, the Medicare conversion factor (the amount Medicare pays per relative value unit [RVU]) was set at $35.8228. The 2015 Final Rule is still governed by the Sustainable Growth Rate (SGR) formula, which has mandated continuing annual cuts to physician payments, resulting in year-after-year 11th-hour congressional rescues with short-term fixes. The 2015 Final Rule published a conversion factor of $28.2239, representing a 21.2 percent cut to physician payments. Congress does not seem to have the political will to confront the $130 billion task of eliminating the SGR formula, and to date it has opted for a series of short-term legislative patches. On April 1, 2014, President Barack Obama signed into law the Protecting Access to Medicare Act of 2014. The law provided stabilization of the Medicare conversion factor for services through March 31, 2015, after which the 21.2 percent SGR-mandated cuts will have to be confronted once again (Table 1).

2015 Geographic Practice Cost Index Update

The geographic practice cost index (GPCI) is used by CMS to modify payment based on regional differences relating to cost of living, malpractice, and practice cost/expense. Some states have a permanently fixed work GPCI. They include Alaska at 1.5 and the frontier states (Montana, Nevada, North Dakota, South Dakota, and Wyoming) at 1.0. Other states are subject to a work GPCI that ranges from 0.6–1.2. 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 existing 1.0 floor on the physician work GPCI was previously extended through Mar. 31, 2015. The 2015 Final Rule published payment rates that include expiration of the GPCI floor, which will significantly impact more rural areas beginning with dates of service Apr. 1, 2015, absent Congressional action.

ED E/M RVUs Enjoy Slight Increases for 2015

Emergency medicine’s RVU values are remaining stable for 2015. As published in the 2015 rule, emergency medicine will experience a 1 percent update to our overall RVU values in 2015. However, accounting for Medicare’s formulaic rounding processes, the realized gains will be closer to half a percent. Essentially, our RVUs are stable, with 99285 seeing a nearly 1 percent increase. This is independent of any looming change to the conversion factor. The RVUs for our major reimbursement drivers, the E/M codes, have only second decimal point adjustments, which are predominantly due to small changes in practice expense (PE) and liability cost. Of note, the work RVUs have not changed for 2015 and remain stable as they have for the past several years (Table 2).

2015 RVUs for Observation

Observation services were also revalued for 2015, resulting in some small adjustments (Tables 3–5).

Subsequent observation services remained relatively stable from 2014 to 2015 (Table 6).

Critical Care Services

Critical Care Services were also revalued as part of the Final Rule and received small changes (Table 7).

Elimination of the Global Surgical Package for Procedures

CMS has proposed to eliminate the 10-day global and 90-day global package for most procedures. In effect, the RVUs would be lowered substantially and follow-up care would not be included with the payment for the initial procedure. CMS proposed to make this transition for procedures with a 10-day global in 2017 and for those with a 90-day global in 2018. ED providers would continue to bill for procedures such as incision and drainage, joint reductions, etc. However, the RVUs would be significantly reduced. However, upon a patient’s return to the ED for additional care, the opportunity might exist to report 9928x for those follow-up visits.

Regulatory Update: Physician Quality Reporting System

The Physician Quality Reporting System (PQRS) continues for 2015. While 2014 PQRS included small bonuses, 2015 simply has a penalty component. Groups not reporting PQRS measures in 2015 will receive a 2 percent penalty assessed against their 2017 Medicare allowables.

Beginning in 2015, the CMS’s Physician Compare website, in addition to continuing to report basic physician-identifying information, will also display a green check mark for those satisfying the Maintenance of Certification (MOC) requirements. For 2015, CMS retired 50 PQRS measures, including four measures frequently utilized by emergency physicians:

• #28: Aspirin for acute myocardial infarction
• #55: 12-lead ECG for syncope
• #56: Pneumonia (CAP): vital signs
• #59: Pneumonia (CAP): empiric antibiotic

2015 Value-Based Modifier (VBM)

The Affordable Care Act requires CMS to apply a VBM to physician payments for all providers by 2017. For 2015, groups with 10 or more providers will be subject to a VBM penalty of -4 percent. The VBM penalty will be applied to 2017 payments based on 2015 reporting. The VBM penalty will be avoided if at least 50 percent of the providers within a group satisfy the minimum PQRS reporting requirements in 2015.
For additional detail regarding 2015 PQRS, visit the ACEP website.

2015 CPT Coding Changes

The CPT book is published annually, and for 2015, there are 143 deletions, 134 revisions, and 264 CPT code additions, totaling 541 changes. The code changes impacting emergency medicine are listed below.

The following codes have been added for 2015:

A new code set now exists to describe arthrocentesis performed with ultrasound guidance. The code set is further delineated by the size of the joint:

• 20604 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) with ultrasound with permanent recording and reporting.
• 20606 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa with ultrasound with permanent recording and reporting.
• 20611 Arthrocentesis, aspiration and/or injection; major joint or with ultrasound with permanent recording and reporting.

The previously existing codes—20600, 20605, and 20610—have been revised to now include the phrase “without ultrasound guidance.”

The following code has been deleted for 2015:

• 21800 Closed treatment of rib fracture, uncomplicated, each.

ICD-10 Update

The ICD-10 implementation date has been pushed back to Oct. 1, 2015. As such, the current diagnosis code set has been frozen, with new diagnosis codes only allowed for key and novel diseases.

Dr. Granovsky is president of LogixHealth, an ED coding and billing company, and currently serves as the course director of ACEP’s Coding and Reimbursement courses.