This article was developed to provide a summary of the highlights related to the coding of hospital clinic and emergency department visits, as published in the CY 2008 Outpatient Prospective Payment System (OPPS) final rule, that was published in the Federal Register on November 27, 2007.
Clinic visit coding
Hospitals are to continue using CPT evaluation and management (E/M) outpatient visit codes, including the differentiation between new and established patients. For hospital reporting, the distinction between “new” and “established” patients is whether the patient already has a hospital medical record number created within the past 3 years. (This distinction does not differentiate as to the type of service to which the medical record number may be related). In other words, it does not need to be the same type of service in order to be considered an “established” patient. The Centers for Medicare & Medicaid Services (CMS) has continued to observe significant cost differences between new and established patient visits of the same level. CMS is specifically soliciting comments on the definitions of new and established patient visits in the hospital outpatient department.
CMS will discontinue recognizing consultation E/M codes under OPPS and will instruct hospitals to report instead a new or established visit code.
Emergency department visit coding
For CY 2008, CMS is retaining the same definitions to distinguish Type A and Type B Emergency Departments (ED) based primarily on whether or not the department was open 24 hours a day, seven days a week. CMS believes that the main distinguishing feature between Type A and Type B EDs to be the full time versus part-time availability of staffed areas for emergency medical care, not the process of care or the site of care (on the hospital’s main campus or off-site).
Critical Care Coding
CMS reiterated that hospitals should continue to provide a minimum of 30 minutes of critical care services in order to report CPT code 99291, Critical care evaluation and management of the critical ill or critically injured patient; first 30-74 minutes, according to the CPT code descriptor and CPT instructions. If fewer than 30 minutes of critical care are provided, hospitals should report the appropriate clinic or emergency department visit code consistent with their internal guidelines.
Visit Reporting Guidelines
For CY 2008, CMS did not implement national visit guidelines for clinic or ED visits. Instead, hospitals should continue to report visits according to their own internal hospital guidelines.
Based on their analyses for the CY 2008 proposed rule, CMS believes that both clinic and emergency department national visit distributions appear normal and relatively stable over time, indicating that hospitals as a whole are reporting the full range of visit codes in an appropriate manner. In the absence of national guidelines, CMS will continue to regularly re-evaluate patterns of hospital outpatient visit reporting at varying levels of disaggregation below the national level to ensure that hospitals continue to report appropriately and differentially for these services.
CMS has identified 11 principles that hospitals’ internal coding guidelines for visit coding are expected to follow. The first six principles have been reaffirmed, while the next five have been newly added for CY 2008.
- 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;
- 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;
- Guidelines should not change with great frequency;
- Guidelines should be readily available for fiscal intermediary (or, if applicable, Medicare administrative contractor) review; and,
- Guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources. CMS provided clarification regarding these principles as follows:
- 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.
- 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.
- 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.
- 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 use the hospital’s internal guidelines as a reference when auditing the hospital’s ED and clinic records.
- Hospitals should use their judgment to ensure that their coding guidelines can produce results that are reproducible by others.
- 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.
CMS will continue to work on national guidelines and they continue to encourage comments and submissions of successful models. In the meantime, they will require each hospital’s internal guidelines to meet the 11 principles stated above.