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Table of Contents:

January 2016
CPT Code Changes for 2016
2016 Physician Fee Schedule
KPIs Help EDs Remain Profitable
CMS Expands Quality Data
CMS HAC Conditions Reduction Program
Hospital Injury Rates Plateau
4 Ways to Reduce Admissions
Improving Patient Engagement

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CPT Code C ha nges for 2016

Current Procedural Terminology (CPT) 2016 contains
new and revised codes for a variety of services and
procedures related to emergency medicine services.
McKesson Business Performance Services
(McKesson) has prepared this summary to provide you
with details on CPT code additions, deletions and
modifications issued by the American Medical
Association (AMA).
Procedural Code Changes
In CPT 2016, there are more than 300 code updates.
This document discusses codes specific to the
emergency medicine division.
Evaluation and Management
Prolonged service codes 99354 and 99355 are used
when a physician or other qualified health care
professional provides prolonged service(s) beyond the
usual service in either the inpatient or outpatient
setting. Psychotherapy code 90837 was added to the
prolonged service(s) description in the CPT manual.
Time spent performing separately reported services

other than E/M or psychotherapy service is not

counted toward the prolonged service time. This
service is reported in addition to the E/M at any level
or code 90837 psychotherapy and 60 minutes with
patient and/or family member. Prolonged clinical staff
services with physician or other qualified healthcare
professional supervision codes 99415 and 99416 are
new to CPT that involves clinical staff face to face time
beyond the typical time of the E/M service.
The Surgery section had numerous changes starting
with the expansion of the guidelines to include
instructions for the use of imaging guidance.
However, most of the new and revised procedures to
CPT 2016 are not procedures typically performed in
the emergency department. One new code from the
Auditory System section of Surgery, 69209, was
developed and added to the External Ear subsection
to report the removal of impacted cerumen by irrigation
and/or lavage. This new code was developed to
differentiate between the approaches to remove the
impacted cerumen. Code 69210 is the direct method
of cerumen removal by using curettes, hooks, forceps,
and suction.
Do not report 69209 with 69210 when performed on
same ear. For bilateral procedure, you can report
69209 with modifier 50. When the cerumen is
impacted and instruments are required, as mentioned
above, use code 69210.


2016 CPT Professional Edition, AMA, Page 32.

Ibid at Page 418.

The Radiology section changes are also numerous in
numbers and include revisions to guidelines, code
descriptors and parenthetical notes to replace the term
film(s) with image(s) to conform to the current
practice for imaging procedures. The definition of
written report has also been revised for 2016. A
written report (i.e., handwritten or electronic) signed by
the interpreting individual should be considered an
integral part of a radiological procedure or
interpretation. With regards to CPT descriptors for
radiological services, images refer to those acquired
in either an analog (i.e., film) or digital (i.e., electronic)
The Medicine section shows that ALL of the vaccine
codes (90476 90749) have been updated to include
Advisory Committee on Immunization Practices (ACIP)
abbreviations. Codes that represent obsolete vaccine
products have been deleted and 2 new codes were
added to report the administration of serogroup B
Meningococcal (MenB) vaccines and a new code for
the administration of a live oral cholera vaccine.
Category II Codes
The Category II codes section, which are used for
performance measurement, updated code 6030F to
comply with the revision of the Prevention of CatheterRelated Bloodstream Infections (CRBSI) this codes
is used for the PQRS Measure # 76 on Central
Venous Catheter Insertion Protocol.
Category III Codes
The Category III codes section contains a temporary
set of codes for emerging technology, services, and
procedures. If a category III code is available, this
code must be used and reported instead of a category
I unlisted code
View the complete McKesson summary of CPT codes
for emergency medicine (PDF, 83 KB).

This commentary does not supplant the American Medical

Associations (AMA) current listing of Current Procedural
Terminology (CPT) codes, its documentation in the annual CPT
Changes publications, and other related publications from the AMA,
which are the authoritative source for information about CPT
codes. Please refer to your 2015 CPT Code Book, annual CPT
Changes publication, HCPCS Book and Payer Bulletins for
additional information, including additions, deletions, changes, and
interpretations that may not be reflected in this document.
CPT is a registered trademark of the AMA. The AMA is the owner of
all copyright, trademark, and other rights to CPT and its updates.
MLN Matters is a registered trademark of the U.S. Department of
Health and Human Services.

2016 Physician Fee Schedule for

Emergency Medicine
On Oct. 30, 2015, the Centers for Medicare &
Medicaid Services (CMS) issued a Final Rule that
updates payment policies, payment rates, and quality
provisions for services furnished under the Medicare
Physician Fee Schedule (PFS) on or after Jan. 1,
2016. This year, CMS finalized a number of new
policies, including several that are a result of recently
enacted legislation. In addition, the rule includes
discussions regarding:

Robert P. Bunting
Compliance Emergency Medicine
McKesson Business Performance Services


ICD-10-CM, 2016 Complete Official Code Set, Chapter 5, Page

533, Mental, Behavioral and Neurodevelpmental Disorders
(F01-F99), AAPC, Optum360 2015.

Ibid at Page 427.

ReveNews Emergency Medicine

ICD-9-CM, 2014, Sixth Edition, 9th Revision, Clinical

Modification, Volume 1, Chapter 5, Page 86, Mental,
Behavioral and Neurodevelopmental Disorders (290-319),
Editor Anita C. Hart, Optuminsight August 2013.
Merck Manual, Section 15 - Psychiatric Disorders, Chapter 187
Anxiety Disorders, Page 1512 - 1516, Gary Zelko, Publisher,
June 1999.
Anxiety Disorders. WebMD.

Potentially Misvalued PFS Codes

Telehealth Services
Advance Care Planning Services
Establishing Values for New, Revised, and
Misvalued Codes
Target for Relative Value Adjustments for
Misvalued Services
Phase-in of Significant RVU Reductions
Incident to policy
Portable X-ray Transportation Fee
Updating the Ambulance Fee Schedule
Changes in Geographic Area Delineations for
Ambulance Payment
Chronic Care Management Services for RHCs and
HCPCS Coding for RHCs

Payment to Grandfathered Tribal FQHCs that

were Provider-Based Clinics on or before April 7,
Payment for Biosimilars under Medicare Part B
Physician Compare Website
Physician Quality Reporting System
Medicare Shared Savings Program
Electronic Health Record (EHR) Incentive
Value-Based Payment Modifier and the Physician
Feedback Program

This is the first PFS final rule since the repeal of the
Sustainable Growth Rate (SGR) formula by the
Medicare Access and CHIP Reauthorization Act of
2015 (MACRA). The calendar year 2016 PFS final
rule is one of several final rules reflecting a broader
Administration-wide strategy to create a healthcare
system that results in better care, smarter spending,
and healthier people.
A Fact Sheet provided by CMS, discusses the
changes to payment policies and payment rates for
services furnished under the PFS and other programs.
Summary CMS Outpatient Prospective Payment
System and Ambulatory Surgery Center Payments
On Oct. 30, 2015, CMS released the Calendar Year
(CY) 2016 Hospital Outpatient Prospective Payment
System (OPPS) and Ambulatory Surgical Center
(ASC) Payment System policy changes, quality
provisions, and payment rates final rule with comment
period (OPPS/ASC final rule) [CMS-1633-FC]. The
Final Rule updates Medicare payment policies and
rates for hospital outpatient departments (HOPDs),
ASCs, and partial hospitalization services provided by
community mental health centers (CMHCs), and
refinements to programs that encourage high-quality
care in these outpatient settings. OPPS payment
amounts vary according to the Ambulatory Payment
Classification (APC) group to which a service or
procedure is assigned. The final rule also includes
important changes to the Two Midnight Rule effective
beginning in CY 2016. See the related fact sheet for
detailed information.

Medicare Program; Revisions to Payment Policies Under the

Physician Fee Schedule and Other Revisions to Part B for CY
2016; Final Rule. Nov. 16, 2015. 42 CFR Part 405, 410, 411, et
al. Pages 70888-70889
CMS. Proposed policy, payment, and quality provisions changes
to the Medicare Physician Fee Schedule for Calendar Year 2016.
Fact Sheet. Oct. 30, 2015.

ReveNews Emergency Medicine

CMS continues to look for ways to improve their

methodologies for estimating the costs associated with
providing services, including the methodology for
packaging services. This will continue in future years.
They have finalized the proposed rule without making
changes to the packaged revenue codes relating to
anesthesia which include Anesthesia General
Classification, Incident to Radiology, Incident to other
DX Services, or Other Anesthesia. Anesthesia
providers billing separately for their services would not
be impacted.
View complete McKesson Summary of the 2016 PFS,
OPPS and ASC Policy Changes for Anesthesia and
Pain Management (PDF, 271.4 KB)
Robert P. Bunting
Compliance Emergency Medicine
McKesson Business Performance Services

Key Performance Indicators Help EDs

Remain Profitable
Emergency departments face special challenges when
it comes to managing the revenue cycle. Not only are
many of their patients uninsured, but the
documentation requirements for coding to the
appropriate level of service typically are more rigorous
and complex in the ED than in other specialties.
That means emergency groups must be at the top of
their game if theyre going to maintain optimal cash
flow and profitability, according to Bill Simpson, vice
president of client management for McKesson
Business Performance Services (McKesson).
To help groups stay sharp, Simpson has identified
some key performance targets that all emergency
medicine groups should strive to achieve:

Chart Completion Percentage: End of Month95% and at Month 2-100%

There really isnt any more fat to cut from a lot of
practices, Simpson said. As a result, he said, it is
critical that charts be completed as accurately and
as quickly as possible.

Medicare Program: Hospital Outpatient Prospective Payment and

Ambulatory Surgical Center Payment Systems and Quality
Reporting Programs pages 70318 - 70321

Its easy for clinicians to miss documentation due

to the chaotic nature of emergency medicine. But
you want to make sure that youve accounted for
every patient that has presented and that every
chart is completed.
Groups should develop a systematic process for
monitoring patient charts to make sure that all
necessary documentation is included. McKesson,
for example, has developed a proprietary platform
that collects data needed to file claims and flags
practices regarding any open issues.

A lot of time groups dont pay attention to

onboarding and that can have major cash flow
implications, particularly if the new physician is
covering multiple shifts for colleagues whove
taken time off, Simpson said.

Year-to-Date Cash Performance versus Same

Period Prior Year:
Seasonality can have a major impact on
emergency medicine. Volume in Arizona, for
example, tends to pick up in the winter when
snowbirds arrive, and fall off in the summer due to
the heat. Similarly, seasonal flu cases can have a
significant impact on ED volume throughout the
country. Thats why it is important to measure
cash performance against the year-earlier month,
as opposed to the previous quarter. This will help
practices identify seasonal trends and in so doing,
make more accurate projections.

Registration Denial Percentage: <10%

This metric provides insight into the effectiveness
of the front office by tracking registration accuracy.
If denials stemming from registration problems
exceed 10%, groups should look closely at the
registration process to determine how it can be

Collection Agency Recovery: Between 4% and

Agency recoveries should average between 4-7%
of bad debt submitted for collection. If the number
is greater than 7%, an audit needs to be done to
make sure theres nothing wrong with the
demographics on the front end or that other
problems dont exist on the back end. If it is under
4%, there may be a problem in the exchange of
information with the collection agency or some
other performance-related issue.

What youre trying to avoid are charts that are

sent back from coding because theyre missing
critical information. That can really kill timely
reimbursement and consistent cash flow,
Simpson said.

Left Without Treatment (LWOT) as a

Percentage of Census: < 2%
Patients who elect to depart a crowded emergency
room before being treated represent a lost
revenue opportunity. Groups should therefore
strive to keep wait times down, and work with
hospitals to ensure that beds and nursing staff are
available. Tools for reducing wait times can
include initial patient triage and quick registration,
team evaluation of higher acuity patients and
bedside order entry.
Down-codes: < 2%
Clinicians need to be cognizant of the level of care
theyre providing and document the details needed
to substantiate what they did and why. They
should also establish a method for monitoring the
process. Each month, McKesson provides clients
with detailed reports that indicate which services
were coded to a lower level of service due to
Failure to document necessary information. If the
number of down-codes exceeds 2%, in-services
aimed at improving documentation should be
scheduled with the providers responsible for the
Enrollment Holds: < $20,000
Working to ensure that all new-hire credentialing
with public and commercial payers is completed
as quickly as possible is essential to steady cash
flow, Simpson said. Enrollment holds are an
important marker that can reflect problems with
the onboarding process.

ReveNews Emergency Medicine

Other Tips for Sustaining Profitability

Make sure your demographic feeds from the
hospital are sending accurate insurance updates
to the billing company. The billing company also
needs to have direct contact with the hospital
billing department to address registration problems
or bad data.

Get rid of paper: Any process that is manual

needs to be automated.

Make sure your billing company has access to

both lockbox deposits and electronic fund
transfers. This way, billing staff can balance bank

statements to confirm that all of the claims have

been posted.

Work with your physicians and coders to make

sure that even the smallest details of care are
captured, including call to floor, EKGs, fracture
care, tobacco counseling, after hours charge and
the like. Measure these fee-generating services as
a percentage of volume and then monitor monthly.

Make sure manage care contracts are paying

correctly. Develop a matrix that lists payers,
contract terms and rates for all EM levels and use
it to make regular comparisons to paid claims.
Equally important, dont be passive and let
contracts that come up for renewal roll over year
after year. Take action each year and ask for an

When negotiating contracts with payers, try not to

get too focused on procedure reimbursement,
since in most cases, 95% of the total revenue
comes from evaluation and management (E&M)

Finally, Simpson says its important to keep the

revenue cycle in perspective and remember that the
perfect can be the enemy of the good.
If your doctors are close to hitting their numbers, tell
them theyre doing a good job and dont use reports to
beat them up, he said. Reports can be important
learning tools, but remember that billing patients is not
the same as treating them. No one is going to die if a
mistake is made. So give them a break.

CMS Expands Quality Data on

Physician Compare and Hospital
In a CMS press release issued December 10, CMS
announced that data was refreshed on both
the Physician Compare and Hospital
Compare websites to improve these consumer online
New quality measures have been added
to Physician Compare for group practices and
Accountable Care Organizations (ACOs) and, for
the first time, individual health care professionals.
These measures focus on the quality of care
provided by Medicare physicians and other health
care professionals.

ReveNews Emergency Medicine

Hospital Compare includes information on more

than 100 quality measures and over 4,000
hospitals. The website has been refreshed and
updated to include new data and several new
For more information: See the Public Reporting of
2014 Quality Measures on the Physician Compare and
Hospital Compare Websites fact sheet.

CMS Hospital-Acquired Conditions

Reduction Program: FY 2016 Results
A fact sheet was issued December 10 announcing in
FY 2016, 758 out of 3,308 hospitals subject to the
Hospital-Acquired Condition (HAC) Reduction
Program are in the lowest performing quartile and will
have a one percent payment reduction applied to all
Medicare discharges occurring between October 1,
2015, and September 30, 2016. In FY 2015, 724
hospitals were subject to a payment reduction. CMS
estimates that the total savings in FY 2016 will be
$364 million.
The fact sheet includes information on:
Public reporting
Measure selection and calculation
Scoring methodology
Additional information about the HAC Reduction
Program is available on QualityNet.

Hospital Injury Rates Plateau, After 3

Years of Decline
In an article released by NPR on December 3, it was
stated that the rate of avoidable complications
affecting patients in hospitals leveled off in 2014, after
three years of declines, according to a federal report
released Tuesday. Hospitals have averted many types
of injuries where clear preventive steps have been
identified, but they still struggle to avert complications
with broader causes and less clear-cut solutions,
government and hospital officials said. The
frequency of hospital complications last year was 17
percent lower than in 2010 but the same as in 2013,
indicating that some patient safety improvements
made by hospitals and the government are sticking.
But the lack of improvement raised concerns that it is
becoming harder for hospitals to further reduce the
chances that a patient may be harmed during a visit.

Four Ways to Reduce Admissions

FierceHealthcare recently released a report that stated
healthcare leaders may need to think outside the box
to reduce readmissions and consider solutions beyond
the hospital's walls. They feel the following four,
lesser known ideas, can have an impact on reducing
hospital readmissions.
1. Assess Community Factors
Thirty day readmission rates dropped by 60% for
targeted diagnosis-related groups when three
western Pennsylvania hospitals launch a program
that connected patient navigators with patients.
These navigators helped patients find valuable
health services and schedule appointments as
well as followed up with the patients after

Tribune, there are ways to improve patient

Understand patients' goals: To improve patient
communications, Claudia Nichols, founder of Pilot
Health Advocates suggests asking the patient to
write down their goals so they can be discussed at
the appointment.
Share notes. Care efficiency has been shown to
improve when physicians share their notes with
their patients. This process also helps promote
communication while improving the patients
participation in their care.
Recognize patients' level of health literacy.
Many patients dont understand the health
information provided by their doctors. Assessing
the patients ability to understand their issues can
help the physician determine what resources they
can benefit from.

Health coaches at the Mercy Clinic (Des Moines,

IA) provide education on the patients condition,
help coordinate case and find resources that will
provide the patient with the most value.
2. House Calls
Two hospital systems, Valley Hospital
(Ridgewood, NJ) and North Memorial Health
System (Minneapolis/St. Paul, MN) have seen
reductions in readmissions by launching programs
that utilize paramedics, emergency medical
technicians and critical care nurses to coordinate
follow-up care.
3. Transitional Care Programs
A 20% reduction in readmissions was seen by
Community Care of North Carolina after they
launched a physician-led transitional care program
in 2008.
4. Emergency Departments for Elderly Patients
Because elderly patients can have an increased
issue with performing daily tasks after surgery,
they are at high risk for readmissions. However,
emergency rooms can be confusing. Several
hospitals have created special emergency
departments for elderly patients with specially
trained staff to assist this patient population by
assessing patients for readmission risk factors.

Improving Patient Engagement

Today patients are more engaged in their healthcare
but barriers still exist toward the transition to true
patient-centered care. As reported by Fierce Practice
Management, and based on an article in the Chicago

ReveNews Emergency Medicine

If you have questions about information contained in this issue of

Emergency Medicine ReveNews, or would like more information
about McKessons Business Performance Services please contact
your account manager or contact us at 800.789.6276, e-mail
emergencymedinfo@mckesson.com or visit
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