The Central Office on HCPCS continues to receive requests for assistance in the assignment of appropriate evaluation and management (E/M) codes for hospital clinic and emergency department (ED) visits. While the Central Office on HCPCS appreciates your concerns regarding the coding and reporting of E/M services for hospital clinic and ED visits, and because at present there are no national visit guidelines, we cannot provide guidance for the reporting of these services. The Centers for Medicare & Medicaid Services (CMS) has consistently instructed hospitals to continue reporting visits based on their own internal hospital guidelines.
In CY 2008, OPPS Final Rule published November 28, 2007, CMS provided a list of 11 principles for hospitals to follow to assist in the development of the hospital’s internal coding guidelines for visit coding. The Central Office on HCPCS published the 11 principles in the Fourth Quarter 2007 issue of AHA Coding Clinic for HCPCS. Here is a reprint of the 11 principles provided by CMS.
- Guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
- Guidelines should be based on hospital facility resources, not physician resources.
- Hospital-specific guidelines should not be based on physician resources. However, this does not preclude a hospital from using or adapting the physician guidelines if the hospital believes that such guidelines adequately describe hospital resources.
- Guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
- Guidelines should meet the Health Insurance Portability and Accountability Act (HIPAA) requirements.
- Guidelines should only require documentation that is clinically necessary for patient care.
- Guidelines should not facilitate upcoding or gaming.
- Guidelines should be written or recorded, well-documented and provide the basis for selection of a specific code.
- Guidelines should be applied consistently across patients in the clinic or ED to which they apply.
- Hospitals with multiple clinics may have different coding guidelines for each clinic, but the guidelines must be applied uniformly within each separate clinic. Hospital’s assorted set of internal guidelines must measure resource use in a relative manner, in relation to each other.
- Guidelines should not change with great frequency.
- CMS would generally expect hospitals to adjust their guidelines less frequently than every few months, and they believe that it would be reasonable for hospitals to adjust their guidelines annually, if necessary.
- Guidelines should be readily available for fiscal intermediary (or, if applicable, Medicare administrative contractor) review.
- Hospitals should use their judgment to ensure that coding guidelines are readily available, in an appropriate and reasonable format. CMS would encourage fiscal intermediaries (FI) and Medicare Administrative Contractors (MACs) to review a hospital’s internal guidelines when an audit occurs.
- Guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.
- Hospitals should use their judgment to ensure that their coding guidelines can produce results that are reproducible by others.
Additionally, CMS has stated administrathat hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. Hospitals with more specific questions related to the creation of internal guidelines are encouraged to contact their local FI or MAC.
An update on hospital clinic and emergency department visit coding was published in the Fourth Quarter 2008 issue of AHA Coding Clinic for HCPCS. According to the update, hospitals are still required by CMS to continue reporting hospital clinic and ED visits based on their own internal hospital guidelines in the determination of the different levels of clinic and ED visits for calendar year (CY) 2009. In addition, under the OPPS, changes were made to the meanings of “new” and “established” patients. As of CY 2009 the distinction is whether or not the patient has been registered as an inpatient or outpatient of the hospital within the past three years.
Many of the coding requests received in our office indicate that more hospitals continue to struggle with the reporting of these services. Here are a few samples of general questions received and responses provided that may be of assistance to you.
Based on clinical documentation in the health record an established patient with a nonhealing wound of the left lower extremity returns from the Wound Care Center with an established plan of care for continued follow-up evaluation and treatment. What type of documentation would be necessary to support the coding of a separately identifiable evaluation and management (E/M) code (based on our facility’s matrix) with a modifier 25 along with CPT code 17250, Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) which was reported for the chemical cauterization of the nonhealing wound?
According to CPT coding guidelines, if on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed, it would be appropriate to append modifier 25 to the appropriate level E/M service provided.
Per information provided on the CMSs Web site, https://questions.cms.hhs.gov, Frequently Asked Question, number 8810, “Billing a visit code in addition to another service merely because the patient interacted with hospital staff or spent time in a room for that service is inappropriate. A hospital may bill a visit code based on the hospital’s own coding guidelines, which must reasonably relate the intensity of hospital resources to the different levels of HCPCS codes. Services furnished must be medically necessary and documented.”
May a hospital bill for the facility- based evaluation and management services associated with a patient visit in the emergency department if a nurse or mid-level provider, but not a physician, provided the patient with treatment during the visit?
Per information provided on the CMS Web site, https://questions.cms.hhs.gov, Frequently Asked Question number 8810, “Under the OPPS, unless indicated otherwise, CMS does not specify the type of hospital staff (for example, nurses, pharmacists, etc.) who may provide services in hospitals because the OPPS only makes payments for services provided incident to physicians’ services.
Hospitals providing services incident to physicians’ services may choose a variety of staffing configurations to provide those services, taking into account other relevant factors such as State and local laws and hospital policies.
Is a hospital facility allowed to bill for facility-based E/M services associated with a patient visit to the facility’s emergency department?
Yes, it is appropriate to report an E/M code for the facility for a patient visit to the emergency department. However, there is no standardized system for the reporting of facility E/M visits.
The Centers for Medicare & Medicaid Services (CMS) has allowed each facility to develop their own unique internal guidelines to report clinic and emergency department services.
The hospital code assigned for each visit should be based on the hospital’s internal guidelines established for the reporting of outpatient hospital ED services.
A patient arrives at the exam area of a hospital-based outpatient cancer center and a licensed nurse observes that the patient is experiencing shortness of breath.
The nurse performs an assessment within standard nursing protocols, documents the findings, and notifies the physician who orders a blood transfusion to resolve the problem. The patient is transferred to the Infusion Center within the outpatient cancer center.
After the blood transfusion has begun in the Infusion Center, a second nurse in the Infusion Center discovers that the patient has an elevated temperature and performs an assessment within standard nursing protocols, documents the findings, and notifies the physician who orders an antibiotic infusion to resolve the patient’s condition.
The antibiotic infusion is administered to the patient. Can the hospital report two technical E/M services for each assessment?
It would be inappropriate to report two separate E/M services for this case.
Based on the information provided, the patient was moved between departments and this would be considered continuation of care during a single hospital outpatient visit.
Therefore, only one E/M code would be reported.