Nay for CMS Proposed Rules on ED Facility Fees
By Robert Hitchcock, MD, FACEP
The calendar year 2014 Outpatient Prospective Payment System Proposed Rule (CMS-1601-P) proposes several changes that I believe will negatively impact emergency departments (EDs).
The two proposed changes in particular that have me concerned are:
- Consolidation of the five ED facility level evaluation and management (E&M) codes into a single code
- Packaging of add-on services
Consolidation of facility level codes
Without clear facility level guidelines, determining accurate codes is challenging for hospitals and potentially responsible for the recent media stories suggesting that upcoding is occurring. Despite repeated requests for CMS to develop guidelines and much industry input and willingness, no action has been taken. I’m concerned that the proposed consolidation is a substitute for clear facility level guidelines. The methodology for determining reimbursement amounts for the proposed codes are unclear and no impact analysis on hospitals has been performed, or could be from the data presented.
The logic currently used by most hospitals to determine facility E&M codes for ED visits relies on evaluation of the resource requirements to care for the patient during the visit. In many cases, the distribution of patient complexities, and thus facility codes, is often a result of multiple factors – many of which the hospital has no control over.
For example, hospitals in areas where Medicare patients have limited access to primary, preventive, and specialty care may see patients with poorly managed chronic diseases who are more complex and resource intensive. These hospitals may well experience a significant decrease in reimbursement, which may negatively affect their ability to continue to provide healthcare services. In addition, increasing the number of lower acuity Medicare patients treated in the ED will significantly increase total federal healthcare expenditures for unscheduled care.
A tiered structure is essential to the financial stability of hospitals and would help protect against shifting care patterns that could unnecessarily raise healthcare expenditures. Clear, concise guidelines should be developed that allow hospitals to accurately and reproducibly assign the appropriate tiered services code for a particular visit. If simplification of coding guidelines and reimbursement is a main goal, I would suggest one approach would be to shift from five tiers to three. This will allow the healthcare system to continue to track and manage the resources required to provide unscheduled care.
Packaging of add-on services
The proposed packaging of add-on services has a commendable goal of simplifying reimbursement and encouraging hospitals to seek efficiencies in the care they provide. However, some of the proposed packaging involved are for specific therapeutic services that are often required to provide high quality care. I believe that the broad brush of unconditional packaging of all add-on services is inappropriate and could lead to circumstances that are directly detrimental to patient care.
The packaging of add-on services in certain circumstances would be beneficial, such when the provision of the service is not directly related to therapeutic delivery of care, especially medications. For instance, providing additional intravenous doses of an identical medication are often required to provide optimal care (e.g., analgesic administration for pain control or additional intravenous hydration for dehydration). There’s really not much opportunity for improving efficiencies here; either we provide appropriate pain management, or not. The concern lies in that packaging these services may create situations where optimal patient care is pitted against the financial pressures of the hospital.
Preservation of EDs
I believe that the proposed modifications to these two areas would have a negative impact on both national healthcare costs and quality of patient care delivered. As a safety net for healthcare in the US, the preservation of EDs is critical.
The final rule is expected around November 1 and will take effect January 1, 2014.
Robert Hitchcock, MD is chief medical informatics officer of T-System Inc.