For 2012, Medicare is changing the code descriptors for the telehealth codes and expanding the definition beyond inpatients to include the emergency department (Table 4). The originating site’s reimbursement has been increased modestly as well, by 0.6%.

Regulatory Update: The Physician Quality Reporting System (PQRS) continues with a 0.5% bonus for successful reporting in 2012, which will continue through 2014 and transition to the penalty phase beginning in 2015. The CMS Physician Compare website is now live and being populated with basic physician-identifying information. In the 2012 rule, CMS reiterated its commitment to posting physician quality data, such as PQRS scores, on the website for 2013.

CMS has continued its interest in bundling “like procedures” and imposing discounts when multiple services are provided in a single setting. This discounting paradigm, termed Multiple Procedure Payment Reduction (MPPR), was previously limited to the facility or technical component of imaging. It has now been expanded to include the professional component of CTs, MRIs, and ultrasounds. Under MPPR, subsequent studies will trigger a 25% discount. The higher-priced study will be paid at the full fee schedule, and the second study will be discounted. Emergency department ultrasounds fall into the MPPR category of potentially discounted services, and emergency physicians may see expansion of this concept into other areas of diagnostic services.

CPT Coding Changes for 2012

Beginning in 2012 there are several CPT code changes of interest to emergency physicians. Taken from the 2012 CPT book, the highlights below should be incorporated starting Jan. 1.

In the Evaluation and Management (E/M) services guidelines in the front of the book, there is new wording inserted in the section describing the distinction between a New and Established Patient. The definition of a new patient is stated as one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty, who belongs to the same group practice, within the past 3 years.

Similarly, an established patient is one who has received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past 3 years.

The emergency department E/M codes 99281-99285 are not directly impacted by this language. However, if your group staffs an urgent care center, the distinction between new and established patient plays a critical role in determining the code selected for the visit and subsequent reimbursement. Reimbursement for patients classified as “established” is often 30% lower than that of “new” patients.