This month the Centers for Medicare and Medicaid Services (CMS) released its 2018 final rule for the Medicare Physician Fee Schedule, which sets the Medicare payment rates each year.

Is your urgent care billing team prepared for the changes?

Changes to Frequently Reported E/M Codes

The Medicare conversion factor overall will be up in 2018 to $35.99, a 10-cent increase from 2017. But urgent care providers who administer a lot of vaccines will take a payment hit from Medicare in 2018 because administration code 90471 (immunization administration) is taking a 19 percent cut from $25.84 to $20.88. Luckily, that’s the biggest cut in 2018.

Some frequently reported E/M codes are actually getting small payment increases. Office code 99214 (office/outpatient visit established) is getting a 1 percent increase, bringing the non-facility rate from 108.74 to 109.44. Nail debridement code 11721 will increase from $45.58 to $46.44, while eye exam codes 92012 and 92014 will both increase by 3 percent. It should be noted that no changes are being made to G0008, which is administration of the flu vaccine.

CPT/HCPCSDescriptionCY2017CY2018%Change
11721Debride nail 6 or more$45.58$46.442%
90471Immunization admin$25.84$20.88-19%
92012Eye exam established patient$86.49$89.283%
92014Eye exam established patient 1/>visit$125.25$128.523%
99214Office/outpatient visit established$108.74$109.441%
G0008Administration influenza virus vaccineNANANA

As far as any revisions to the E/M documentation guidelines, CMS has decided to make no changes in 2018. According to Part B News, CMS agrees with stakeholders that the guidelines need substantial revisions, but the agency has concluded that comprehensive revisions “would require a multi-year, collaborative effort among stakeholders.” The agency is working on developing a collaborative approach to revamping the guidelines.

Estimated Impact on Urgent Care Clinicians, Facilities

According to the Advisory Board, CMS estimates each year in the final rule which clinicians and facilities will be impacted by the payment changes. This year, diagnostic testing facilities face the largest potential payment cut of 6 percent under the proposed rule. Clinical social workers stand to gain the most, with an estimated 3 percent increase in Medicare payments in 2018.

When it comes to the urgent care industry, CMS says physical/occupational therapy specialties face a 2 percent cut under the proposed rule, while general practice, physicians assistants and nurse practitioners are not expected to be impacted by the payment changes. Although many urgent care centers are primarily staffed with PAs and NPs and administering vaccinations are a core urgent care service, CMS’ estimate is most likely accurate. While there are certainly exceptions, Medicare patients make up about 10 percent of most urgent care centers’ patient mixes, so the payment changes will likely have a minimal impact on urgent care clinicians and facilities overall.

Final Rule Reduces PQRS Measures and Cuts

CMS reduced the minimum number of quality measures practices had to report to avoid a 2 percent penalty under the physician quality reporting system (PQRS) from nine to six. The measures also no longer have to span three National Quality Strategy domains. This means if you reported at least six measures, your 2018 payments won’t receive a PQRS penalty.

CMS is also decreasing cuts in Medicare pay to providers who failed to meet PQRS requirements in 2016. Groups of 10 or more will get a 2 percent reduction instead of 4 percent, and groups of nine or fewer will get a 1 percent reduction instead of 2 percent.

A complete version of the final rule has been published in the Federal Register.

Urgent Care Billing

PV Billing’s urgent care billing specialists are trained to code, process, monitor and collect urgent care claims so they can provide you with end-to-end revenue cycle management.