Perhaps the best reimbursement news of the year for emergency physicians is found in the 2009 Medicare Physician Fee Schedule Final Rule relating to the continued positive effects of the 2007 RBRVS Update Committee (RUC) Five-Year Review.

Following the Five-Year Review, emergency department (ED) reimbursement immediately increased 7% starting in 2007. However, further gains were offset by the Centers for Medicare & Medicaid Services (CMS) instituting a work RVU budget neutrality factor, which disproportionately affected emergency medicine. In 2009 the work RVU budget neutrality factor has been removed and will be applied to the Medicare conversion factor instead, decreasing it from $38.08 to $36.06.

Congress recently approved a 1.1% increase in 2009 Medicare physician payments. This increase went to all physicians as part of the temporary sustainable growth rate (SGR) fix through the end of 2009. Emergency physicians will receive an additional 3% increase based on the change in the application of the budget neutrality factor. The resulting 4% increase is the largest among physician specialties.

See the accompanying table for a comparison of 2008 and 2009 Medicare payments.

• Electronic prescribing (E-Rx): The 2009 Medicare Physician Fee Schedule Final Rule includes E-Rx bonuses (which transition quickly to ongoing 2% penalties for those not performing E-Rx). Because of the lack of direct physician control and the unique nature of emergency departments’ episodic and geographically varied patient population, CMS has elected to “carve out” the emergency department from the E-Rx program, and emergency departments will not be participating.
• Physician Quality Reporting Initiative (PQRI): CMS has currently published 153 PQRI measures of which, at this time, 9 potentially apply to the ED setting. The 2008 PQRI bonus has been increased from 1.5% to 2% for 2009. Final specifications relating to the current year’s measures should be coming soon from CMS.
• Medicare enrollment: Creating some difficulty for ED groups, CMS reduced allowable retrospective billing from 27 months to 30 days. ACEP has issued direct commentary to CMS asking for additional consideration.
• Coding updates and changes: The American Medical Association’s annual update of the Current Procedural Terminology (CPT) codes and descriptions was recently released. Each year after the publication of the new CPT book, ACEP’s Coding and Nomenclature Advisory Committee provides a summary of the most relevant changes for emergency medicine.

Of note this year, the entire section related to pediatric codes has been reformatted, with 17 new codes developed to report pediatric services. Despite these significant changes, the typical ED codes 9928x and the critical care codes 99291/99292 remain the appropriate codes to report pediatric ED services.

For those providing critical care transport of pediatric patients, there are now two new codes to report these services. Codes 99289/99290 were deleted, and the new codes for face-to-face physician care during critical care transport of pediatric patients (24 months or younger) are 99466/99467.

Effective Oct. 1, 2009, several ICD-9 diagnosis code additions and revisions appear that are relevant to emergency medicine:

• 038.12: Methicillin-resistant Staphylococcus aureus (MRSA) septicemia.
• 041.12: Methicillin-resistant Staphylococcus aureus (MRSA), bacterial infection.
• A new set of codes for secondary diabetes is found in the 249.XX code set.
• A new set of headache codes in the 339 series, including: 339.00 (cluster headache syndrome, unspecified); 339.10 (tension-type headache, unspecified); 339.21 (acute post-traumatic headache); 339.22 (chronic post-traumatic headache, other); 339.42 (new daily persistent headaches); and 339.43 (primary thunderclap headache).
• Many new, more specific migraine codes in series 346 describe migraines in greater detail, such as those with aura, intractable migraine, cerebral infarction, and status migrainosus.
• Greater detail is available to report pleural effusion, including 511.81 (malignant pleural effusion).
• Hematuria codes are now more specific, with 599.70 (hematuria, unspecified), 599.71 (gross hematuria), and 599.72 (microscopic hematuria).
• Nonspecific vaginal pain is now a reportable diagnosis, 625.70 (vulvodynia, unspecified).
• The spectrum of illness involving Stevens-Johnson syndrome and erythema multiforme has been expanded to include 695.10 (erythema multiforme, unspecified); 695.11 (erythema multiforme minor); 695.12 (erythema multiforme major); 695.13 (Stevens-Johnson syndrome); and 695.19 (other erythema multiforme).
• Important new fever codes include 780.60 (fever, unspecified); 780.61 (fever presenting with conditions classified elsewhere); 780.62 (post-procedural fever); 780.63 (post-vaccination fever); 780.64 (chills (without fever)); and 780.65 (hypothermia not associated with low environmental temperature).
• Wound dehiscence codes are further refined by 998.30 (disruption of wound, unspecified) and 998.33 (disruption of traumatic wound repair).

See the 2009 ICD-9 book for a complete list of new and deleted codes, or visit the new ICD-9 FAQs on www.acep.org.

Other Resources

Resources for these and other topics can be found in the reimbursement section of the ACEP Web site (www.acep.org). The ACEP Coding and Nomenclature Advisory Committee, the ACEP Reimbursement Committee, and ACEP Reimbursement Department staff members David McKenzie and Mary Ellen Fletcher are available to field your questions. Finally, ACEP holds coding and reimbursement educational conferences twice a year.

Dr. Granovsky is a member of ACEP’s Coding and Nomenclature Advisory Committee. He is president of Medical Reimbursement Systems Inc. (MRSI), an ED billing and coding company.