E/M coding still confusing under final outpatient PPS
June 1, 2000 5 minutes read
E/M coding still confusing under final outpatient PPS
By JoAnn Pata, MS, RHIA, CCS
Health Information Management Consultant
HIM Professional Resources
Philadelphia
Q. The final rule of the outpatient prospective payment system (PPS) states: "Therefore, each facility should develop a system for mapping the provided services or combination of services furnished to the different levels of effort represented by the codes. . . . We will hold each facility accountable for following its own system for assigning the different levels of HCPCS [HCFA common procedure coding system] codes.
"As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes, we will assume that is in compliance with these reporting requirements as they relate to the clinic/emergency department visit code reported on the bill. Therefore, we would not expect to see a high degree of correlation between the code reported by the physician and that reported by the facility."
Does that mean coders would not use the HCFA/AMA (Health Care Financing Admini-stration and American Medical Association) documentation guidelines developed to aid physicians in evaluation and management (E/M) code assignment?
A. According to this Federal Register reference, the HCFA/AMA documentation guidelines don’t even come into play, in my opinion.
What system or methodology for E/M code assignment does HCFA expect hospitals to use? HCFA and the AMA developed documentation guidelines for E/M code assignment in 1994 because both providers and carriers had difficulty assigning and auditing the E/M services codes revised in 1992. If each facility will be held accountable for following its own system for assigning the different levels of HCPCS codes, who will determine whether a facility’s own system reasonably relates the intensity of hospital resources to the E/M outpatient and emergency codes?
I urge coders to go to the beginning of this section, which deals with visit codes, to get the whole picture. It begins on p. 18,450, item 3, "Treatment of Clinic and Emergency Department Visits." In the discussion, HCFA states it had been concerned that certain hospitals’ use of the lowest level code, CPT code 99201, to bill for all clinic visits would distort the data.
That, however, was HCFA’s required reporting per the Medicare Hospital Manual. A facility could report codes 99201 or 99211 as an indicator or "flag" for a medical visit or had the option of reporting visits according to the specific E/M levels. Reporting a code from the five visit levels was not a requirement.
The discussion continues on p. 118,451: "We have developed the weights for clinic visits by using claims data only from a subset of hospitals that billed a wider range of visits rather than relying solely on claims with CPT code 99201. We chose to use this subset of hospitals (for this purpose only) because we do not know what CPT code 99201 indicates when hospitals use it exclusively to bill all visits."
Q. HCFA has developed the weights for visit codes found in this final rule from a subset of hospitals that used a wider range of visit codes. How did hospitals assign E/M codes in 1996, the year used for analysis?
A. From my consulting experience, some hospitals applied the HCFA/AMA documentation guidelines to determine the visit level. Other hospitals used the code for the E/M level found on the emergency department physician’s encounter form used for billing professional services, and some hospitals applied a nursing classification system that was mapped to the existing E/M levels. I don’t believe there has ever been a consistent approach.
The final rule continues, "We emphasize the importance of hospitals assessing from the outset the intensity of their clinic visits and reporting codes properly based on internal assessment of the charges for those codes, rather than failing to distinguish between low- and mid-level visits because the payment is the same. The billing information that hospitals report during the first years of implementation of the hospital outpatient PPS will be vitally important to our revision of weights and other adjustments that affect payment in future years.
"We realize that while these HCPCS codes appropriately represent different levels of physician effort, they do not adequately describe nonphysician resources. However, in the same way that each HCPCS code represents a different degree of physician effort, the same concept can be applied to each code in terms of the differences in resource utilization," the rule states.
To an HIM professional, that statement about assigning visit codes is most disturbing because it suggests a system that is not standardized across the board and that has the potential for abuse. HCFA is asking that codes be reported properly, "based on internal assessment of the charges for those codes. . . ."
Given the variation in charges from hospital to hospital, it could be possible that an emergency department record, for example, would be assigned to a higher E/M level at another hospital, even though the documentation is the same. The billing information hospitals report during the first years of implementation of the hospital outpatient PPS are vitally important to HCFA’s revision of weights and other adjustments that affect payment in future years. But can it be meaningful when there is the possibility for broad variations in E/M level assignment, as the final rule suggests?
Finally, HCFA states, "In the same way that each HCPCS code represents a different degree of physician effort, the same concept can be applied to each code in terms of the differences in resource utilization." I agree that the same concept applied to the different levels of physician effort can be applied to differences in resource utilization. But how can a valid, proven method of doing this be developed by the implementation date? In my opinion, leaving each facility responsible for developing its own system can only lead to chaos.
Q. With this confusion, what would you recommend to hospitals?
A. According to the final rule on p. 18,451, coders will have to learn the mapping system their hospital decides to use, "which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes."
I suggest looking to the American Health Information Management Association, the American Hospital Association, and the state hospital associations for direction in this area. With such a short time left before the July 1 startup, implementing a mapping system to the CPT E/M levels will probably be one of the greatest challenges hospitals will face.
[HIM Professional Resources can be reached at (215) 389-6777.]
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