Since April 2000, hospitals have been using CPT evaluation and management (E/M) codes to report facility resources for clinic and emergency department (ED) visits. Recognizing that the E/M descriptors were defined to reflect the activities of physicians and did not adequately describe the range and mix of services provided by hospitals, the Centers for Medicare & Medicaid Services (CMS) instructed hospitals to develop internal hospital guidelines to determine the level of clinic or ED services. For calendar year (CY) 2007, CMS requested comments on proposed national guidelines for the reporting of these codes.
In addition, CMS had proposed HCPCS G-codes to replace the E/M codes used to report ED and clinic visits.
In 2003, the American Hospital Association (AHA) and the American Health Information Management Association (AHIMA) convened an expert panel and submitted to CMS a recommendation on a model for the reporting of ED and clinic visits, for the complete report go to: http://www.ahacentraloffice.org/ahacentraloffice/images/EM_Coding_Report2.pdf).
The CMS-modified version of the AHA/AHIMA proposed guidelines has been posted on the CMS Web site for comment (http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/CMS1506P_Draft_AHA_AHIMA_Guidelines.pdf).
The modified AHA/AHIMA guidelines contain CMS’ refinements based on comments received from outside hospitals and associations, clinical review, and changing payment policies in the Medicare Hospital Outpatient Prospective Payment System (OPPS) regarding some separately payable services. CMS is seeking public comment on both versions before adopting national guidelines. The public comments received by CMS on the two versions of the guidelines, as well as the national guidelines section of the proposed and final rules are publicly available to interested parties. CMS plans to communicate progress on the development of OPPS visit guidelines through updates to the OPPS Web site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/. In addition, CMS may post other versions of draft guidelines in order to solicit additional public input during CY 2007.
Since there were no national guidelines established by the CY 2007 OPPS final rule, hospitals should continue to use their own internal guidelines. CMS has reiterated its commitment to provide a minimum of 6-12 months notice to hospitals prior to implementation of national guidelines to provide sufficient time for providers to make the necessary systems changes and educate their staff. Because of this commitment, CMS does not expect implementation of national guidelines prior to CY 2008.
CMS does not anticipate that individual hospitals would experience a normal distribution of visit levels, although CMS would expect a normal distribution across all hospitals after national guidelines are established. For example, a small community hospital may provide more low-level services than high-level services, while an academic medical center or trauma center may provide more high-level services than low-level services. CMS has indicated that they expect national guidelines to provide for five levels of coding, to parallel the five payment levels that are finalized in the CY 2007 final rule.
CMS agreed that there may be advantages to including separately payable interventions in the guidelines as examples. Separate payable interventions may provide a measure of acuity that may be lost in the absence of recognition of these procedures.
Clinic visit coding
In response to the numerous comments related to the creation of G-codes for clinic and ED visits, CMS is postponing finalizing G-codes for clinic visits until national guidelines have been established. Many commenters stated that it would be too difficult for them to first transition to G-codes and then to transition to national guidelines shortly thereafter. For CY 2007, hospitals should continue to use CPT codes to report clinic visits.
In the CY 2007 OPPS final rule, CMS has clarified that since CPT code descriptors for E/M clinic visits distinguish between new and established patients, hospitals must continue this distinction. CPT defines an established patient as “one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.” According to the April 7, 2000 OPPS final rule, the meanings of “new” and “established” with regards to hospital visit reporting pertain to whether or not the patient already has a hospital medical record number. If the patient has a hospital medical record that was created within the past 3 years, that patient is considered an established patient to the hospital.
Hospital resources associated with an extended clinic visit involving multiple clinicians should be reflected in the hospital’s internal guidelines used to select the level of the clinic visit. Interdisciplinary team conferences will continue to be reported with HCPCS code G0175, Scheduled interdisciplinary team conference (minimum of three exclusive of patient care nursing staff) with patient present.
Emergency department visit coding
For CY 2007, CMS is making a distinction between two types of emergency departments and referring to them as Type A and Type B emergency departments. Type A emergency departments visits will continue to report CPT emergency department visit E/M codes, while Type B emergency departments visits will be reported with newly created G-codes.
According to the CY 2007 OPPS final rule, a Type A emergency department is a hospital-based facility or department that must be open 24 hours a day, 7 days a week and meets at least one of the following requirements:
(1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; or
(2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment).
Type B emergency departments are defined as emergency departments that incur EMTALA obligations, but do not meet the more prescriptive requirements of a Type A emergency department. A Type B emergency department does not need to be available 24 hours a day, seven day a week. A Type B emergency department must meet at least one of the following requirements:
(1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;
(2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or
(3) During the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment).
For CY 2007, new G-codes have been created for Type B emergency departments because there currently are no CPT codes that fully describe this type of facility. The G-codes will allow tracking of resource costs for Type B emergency departments visits as distinct from Type A emergency department visits and clinic visits.
Each hospital must be evaluated individually for purposes of determining whether to report Type A or Type B emergency department codes. The hospital should make a decision specific to each area of the hospital to determine which codes would be appropriate. A separately identifiable area or part of a facility, which does not operate on the same schedule (that is, 24 hours per day, 7 days a week) as its emergency department, would not be considered an integral part of the emergency department that operates 24 hours per day, 7 days a week.
In general, CMS does not consider it appropriate to treat a satellite emergency department or an area of the emergency department as if it were available 24 hours a day simply because the main emergency department is available 24 hours a day. It may be appropriate for a Type A emergency department to “carve out” portions of the emergency department that are not available 24 hours a day, where visits would be more appropriately billed with Type B emergency department codes.
The HCPCS G codes for Type B emergency department visits are listed in the table below:
HCPCS code - HCPCS code long descriptor
G0380 Level 1 hospital emergency department visit provided in a Type B emergency department.
G0381 Level 2 hospital emergency department visit provided in a Type B emergency department.
G0382 Level 3 hospital emergency department visit provided in a Type B emergency department.
G0384 Level 4 hospital emergency department visit provided in a Type B emergency department.
G0385 Level 5 hospital emergency department visit provided in a Type B emergency department.
In summary, for CY 2007, hospitals should continue to use their own internal guidelines for determining the level of clinic and emergency department visits.
They should also continue to use CPT codes to report clinic visits as well as Type A emergency department visits. Type B emergency department visits should be reported using the newly created G-codes.