Questions & Answers
Volume 24 - May 03, 2012
2012 Emergency Medicine CPT Statistics - Medicare eAdvisory
Each year the Centers for Medicare and Medicaid Services (CMS) publish Part B Medicare Annual Data (BMAD) reporting the usage of CPT codes and Medicare allowed amounts for the prior year. The annual data includes all claims with dates of service in the prior year, processed by Medicare contractors by June 30th of the following year. The Agency estimates that this covers 96% of all claims that will be filed for the year of service.
The BMAD data allows for trend reporting and benchmarking analysis. Some interesting trends appear from the data that independent practices might find helpful when reviewing their own coding practices. It also allows for predictions in net Medicare payment changes for the specialty that result from annual Medicare policy changes. No similar data is available from non-Medicare sources, so benchmarking across all payers is still an estimate.
For example, the tables below show the total RVU changes for each E/M service and the 30 procedure codes most commonly reported to Medicare by Specialty 93 Emergency Medicine in the emergency department setting (not including inpatients or outpatient clinic or other non-ED services). This BMAD data pertained to claims processed before June 30, 2011 for patients seen in 2010.
We compared 2010 Medicare utilization data with data from 2008 to find that ED visits reported by all specialties (including critical care reported by Spec. 93) had increased 5.7%, from 19,052,981 to 20,130,881 visits while allowed amounts for the same E/M services increased from $2,320,375,375 to $2,714,174,631, a 17.0% pay increase.
Some of the increase is explained by RVU and conversion factor changes in the 2-year period that caused payments per RVU for emergency physician services to rise about 6.0%. The rest of the 17% pay increase came from increased overall volume and reporting more intensive services, particularly 99285 and critical care codes. Utilization of these two services went up 15.7% in the two year period and pay allowances increased 22.2%.
The table below shows that in 2005, 99285 services were claimed 37.7% of the time by Emergency Medicine Specialty 93 (CPT 99291 critical care is included as an ED E/M service). By 2010, that rate had climbed to 45.3%, a rise of 20% in use of the high level E/M code. Critical care services, (CPT 99291) rose from a rate of 4.1% in 2005 to 7.1% in 2010, a rise of 73%.
While emergency physician services receive less than 3.0% of the total Medicare Part B payments each year, the use of 99285 has been among the top 10 most expensive CPT codes reported each of the last 5 years. In 2010, we were Number 7 on the list of the most allowed payments for the year. The CPT 99285 generated $1,591,242,089 in allowed amounts in 2010. That is a 21% pay increase from this single CPT code in just 2 years.
This rate of increase in total payments to emergency physicians comes with the price of increased scrutiny as CMS has noticed that ED physician service payments are among the fastest growing visit services in the house of medicine. More Medicare beneficiaries who are aging and getting sicker each year would reasonably require more intensive services. However, higher levels of service are not being reported in the office setting at the rate of increase in the emergency setting. Medicare has been encouraging contractors around the country to perform more medical reviews to determine if inappropriate billing is taking place.
The Medicare contractor for California began in 2011 a statewide pre-payment audit project looking at thousands of ED physician charts for 99285 services. The contractors for Wisconsin, Michigan, Missouri and Kansas have begun doing the same. This is a considerable burden for billers who must track down claim review notices sent to hospital medical records departments or to physicians’ homes. When notices are not received by billers in time to respond within the short 30 day response period Medicare determines that the claim was billed without a medical record existing to support the service. If your physicians receive notices from your Medicare contractor, instruct them to forward these immediately to the billing company. Failure to respond to these requests timely can cause a more comprehensive audit that will add to the burden of securing appropriate payment.
Author: James R. Blakeman, Senior Vice President, Emergency Groups’ Office, Arcadia, CA email@example.com
 Raw data is taken from BMAD data for claims filed by June 30, 2011 for dates of service Jan. 1-Dec. 31, 2010. CMS reports this data by Specialty Designation, HCPCS code, modifier and facility versus non-facility. Physicians who have enrolled with Medicare under the specialty of Emergency Medicine are identified as Specialty 93.Our analysis eliminated all data reported by Specialty 93 for services rendered in a non-facility (office) setting or in the inpatient setting. About 78% of all 99281-99285 ED visit codes were reported by Specialty 93 in 2010.
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