Capturing E/M Services in the

HOPD

AAPC Regional Conference – Anaheim, CALinda Martien, COC, CPC, CPMA

September 2016

Introduction

• A part of the Federal Balanced Budget Act of 1997

required HCFA (now CMS) to create a new Medicare

"Outpatient Prospective Payment System" (OPPS) for

hospital outpatient services

• It was to be separate but similar to the Medicare

prospective payment system for hospital inpatients

known as "Diagnosis Related Groups" or DRG's.

• APC's or "Ambulatory Payment Classifications" are the

government's method of paying for facility outpatient

services for the Medicare program. APC's apply only to

hospitals, and have no impact on physician payments

under the Medicare Physician Fee Schedule.

What is a Hospital Based Clinic?

• An outpatient department of the hospital –just like lab, x-ray, hospital-based clinic.

• Examples of HBC: IV therapy Clinic, Wound Clinic, Pain Clinic, Ostomy Clinic, Oncology Clinic,, ambulatory outpatient clinic, transfusion clinic, OB, anti-coagulation, scheduled visits in the ER

• Example Hospital-Owned Physician Directed Clinic: Physician does own E&M, hospital uses own criteria for their E&M. Two different sets of criteria; two different E&Ms.

Facility vs. Physician E/M Coding

• Facility coding guidelines are inherently different from

professional coding guidelines.

• Facility coding reflects the volume and intensity of

resources utilized by the facility to provide patient care,

whereas;

• Professional codes are determined based on the

complexity and intensity of provider performed work and

include the cognitive effort expended by the provider.

• There is no definitive strong correlation between facility

and professional coding and thus no rational basis for

the application of one set of derived codes, either facility

or professional, to the determination of the other on a

case-by-case basis.

Hospital Owned Physician Directed

Challenges

• Correct claim submission: Physician bills as

hospital based and will receive a reduced fee

schedule payment as the administrative fees are

covered by the facility.

• Place of service as office (POS 11) receives the

full schedule payment in lieu of the reduced

payment. This will ensure the full fee schedule is

received on one 1500 form claim.

The Rules

• At this point, there is no national standard for hospital

assignment of E&M code levels for outpatient services in

clinics and the Emergency Department (ED).

• CMS requires each hospital to establish its own facility

billing guidelines. Further, OPPS lists eleven criteria that

must be met for facility billing guidelines. (see APC

FAQ).

• Facility billing guidelines should be designed to

reasonably relate the intensity of hospital services to the

different levels of effort represented by the codes.

Coding guidelines should be based on facility resources,

should be clear to facilitate accurate payments, should

only require documentation that is clinically necessary

for patient care, and should not facilitate upcoding or

gaming.

Understanding the E/M Process

•E&M = Hospital-based clinic/ER visit charge

• Revenue code 510 CPT Code 99201-99205/99211-

99215/Clinic/Outpatient Dept.

• Revenue Code 450 CPT Code 99281-99285/ER

•APC regulations:

“As long as the services furnished are documented and

medically necessary and the facility is following its own

system, which reasonably relates intensity of hospital

resources to the different levels of HCPC’ codes, we will

assume that it is in compliance with these reporting

requirements as they relate to clinic/emergency

department visit codes reported on the bill.”

(Federal Register vol 65, #68, April 7, 2000,

Page 18451)

Golden Rules – HOPD Charge

Capture

• Always, always bill what

was done first, i.e., actual

procedure: Injection, IV

infusion, laceration repair

• Then evaluate earning

the E&M – as a

separately identifiable

service

• Each visit – look for

three unique billable

services:

– Nursing

procedure/CPT

– Surgical/interventional

procedure/CPT

– E&M

• Not always done, but

look for them!

Evaluate…

• ER & HBC Billing:

– E&M

– Nursing

Procedures/CPT

– Interventional/Surgical

Procedures/CPT

– Know what costs are

being billed that relate

to the above charges

• Physician Billing:

– E&M

– Interventional/Surgical

Procedures/CPT

– E&M levels can be

different, but CPT-4

surgical code should

be the same

What Charges are Covered?

• Nursing Procedure

– Nurse doing the

injection

– Risk of giving the

injection

– Cost of routine

supplies

Separate and

identifiable from the

E&M?

• Surgical Procedure

– Nurse in assistance

– Set up, clean up

– Routine supplies

– Sterilization/tools

– Overhead of room

Separate and

identifiable from the

E&M?

2007 Forward Final Rules

• CMS offers 11 guiding principles:

• 1) The coding guidelines should follow the

intent of CPT code descriptor in that the

guidelines should be designed to

reasonably relate the intensity of hospital

resources to the different level of effort

represented by the codes

Guidelines…

• 2) The coding

guidelines should be

based on hospital

facility resources.

The guidelines should

be not be based on

physician resources

• 3) ..should be clear to

facilitate accurate

payments and be

usable for compliance

purposes and audits

• 4) …should meet the

HIPAA requirements.

Guidelines…

• 5) …should only

require

documentation that is

clinically necessary

for patient care

• 6) …should not

facilitate upcoding or

gaming

• 7) …should be

written or recorded,

well – documented,

and provide the basis

for selection of a code

• 8) …should be

applied consistently

across patients in the

clinic or emergency

department

Guidelines…

• 9) …should not

change with great

frequency

• 10) …should be

readily available for

fiscal intermediary

review

• 11) …should result in

coding decision that

could be verified by

staff & outside

auditors

Specifics of Current E/M Guidelines

• Facility and physician levels are not the

same.

• Create facility-specific leveling system.

• As long as the facility follows it’s own

guidelines – that includes documentation

of the E&M elements = compliance.

• HOLD on any mandated E&M leveling

system. Continue to use internal, auditing,

resource based system.

Understanding the G Codes…• Type A ERs – Paid with newer G codes with each G code

having it’s own payment. (APC 609, 613, 614, 615, 616, 617/CC)

Open 24/7 and staffed as an ER, plus meets licensure issues as a dedicated ER plus EMTALA (pg 335, CMS 1506) --- NOT IMPLEMENTED

• Type B ERs – Paid with newer G codes; included in HBC payment groupers (lesser payment; APC 604-608)

Not open 24/7 / meets licensure issues / EMTALA / during previous calendar year, it provides at least 1/3 of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment. (pg 332, CMS 1506) -IMPLEMENTED

Facility E/M Level Capture

• Facilities do not provide any of the

three key components in an E/M

service

• So how do you choose an E/M level?

Building E/M Criteria

• Working with the care team, brainstorm the detailed

services for each main category:

– Triage/medical screening/EMTALA (ER only)

– Assessment

– Emotional Support

– Teaching

– Discharge Planning/Status

– Interventions (= no CPT-4 code)

– Remember – until mandated system, the E&M is

whatever the facility says it is, with nursing’s

documentation

Example…

• Assessment

Reassess, vital check,

visual acuity, reassess

post meds

• Emotional Support

Patient, family, prolonged

• Teaching

Crutch training, infection

guidelines, walker, new

meds, sling

• Discharge Status

To nursing home, f/u,

physician, by ambulance

• Interventions – no CPT

Enema, observation post-

med, IV attempts, IV more

than 2 lines, Admit, rape

exam, wound cleansing,

ring removal, restraint,

rectal exam, 2 nurses,

flushes, care coordination

• Miscellaneous

Language barrier, behavior

issues, coordination of

care, holding/waiting bed;

holding/waiting for a ride

Example Acuity Resource E/M

Assessment

• Reassessment after meds –10

• Repeat vital signs – 5 pts

• Visual Acuity – 5 points

Teaching

• Ed requiring demo –20

• Ed w/2 or more meds –10

• Crutch training – 5

• Post wound care – 20

• Sling, ace wrap-minor – 5

Emotional Support

Discharge Status

Interventions

Continue brainstorming

services, assigning

points based on risk,

acuity and resource

consumption.

Each visit, the E&M

leveling form is used to

determine level of E&M

to bill.

Completing the E/M Acuity Tool

• Add points and assign to level

based on totals

• All elements of the E&M must

be charted

• Hint: Explore dating and

signing the E&M leveling sheet

and making it part of the

permanent medical record

• Match charting to E&M form as

much as possible

Facility ED Leveling Methodology

• Diagnosis driven– Like diagnoses consume like amounts of resources,

similar to DRGs

• Time driven– Similar services consume like amounts of resources,

similar to APCs

• Point driven– Each service provided is assigned a point value. The

total of the points drive the level assigned. Points

may NOT be assigned for a service that can be billed

separately.

Facility ED Leveling Methodology –

sample Point System

5 POINTS 10 POINTS 15 POINTS 20 POINTS

Initial Assessment BP Monitoring Pelvic Exam Admit ICU/CCU

Wound Cleanse - simple Apply Clavicle Strap Transport to ICU Apply/Monitor Restraints

Topical Meds Foley Cath Sample Enema/Disempaction

Cardiac/Thrombolytic

Agents

Ace Wrap Emotional Support Multiple VS Checks Rape Exam

Urine Dip Cardiac Monitoring IV Insertion Multiple IV Infusions

Steri-strip Application Accompany to Lab/Rad Newborn Care

99281 5-20 points

99282 21-30

99283 31-40

99284 41-50

99285 51 ormore

99291 61 or more

Facility ED Leveling Methodology –

sample Matrix System CPT 99283 Could include interventions from previous levels, plus any of: Minor trauma

Receipt of EMS/ambulance patientMedical condition requiring prescription drug management

Heparin/saline lock Fever that responds to antipyretics

One (1) nebulizer treatment Headache-hx of, no serial exam

Preparation for lab test described in CPT Head injury-w/o neurologic symptoms

Preparation for EKG Eye pain

Preparation for plain x-rays on only one (1) area Mild dyspnea-not requiring oxygen

Prescription medication administed PO

Foley catheter; In and Out cath

C-spine precautions

Fluorescein stain

Emesis/Incontinent care

Prep or assist w/procedures such joint aspiration/injection, simple fracture care

Mental Health-anxious, simple treatment

Routine psych medical clearance

Limited social worker intervention

Post morten care

Direct admit via ED

Discussion of discharge Instructions (moderate complexity)

Billing Services in Addition to the E/M

• Program Memorandum A-00-40 & A-01-80 = 25

modifier = separate identifiable services.

• Golden rule: Always get the CPT-4 procedure

code. Earn the E&M as the separate service.

• Inherent nursing in all procedures/CPT-4 codes

• ER = Triage = separate identifiable = add E&M

• Clinic = procedure + unplanned outcome of

treatment or other medical condition = E&M

• Ensure the E&M criteria is well charted in

addition to the Procedure Code (separate

identifiable E&M)

Practice Scenario #1• Patient presents to ED with complaints of nausea, vomiting,

fever since last night. The patient is otherwise healthy but

very distressed, emotional support provided. Initial

assessment is completed by the nursing staff, including vital

signs, with prolonged emotional support provided. Patient is

seen by ED physician who conducts an expanded problem

focused history, expanded problem focused exam and

medical decision making of low complexity. She orders labs

and an abdominal x-ray, all of which are negative. Tigan

suppository given for nausea/vomiting. The patient is

discharged home with simple instructions to rest, hydrate,

and Tylenol for fever, if continues with Rx for Tigan

suppositories for the nausea/vomiting. Assessment: flu

Practice Scenario #1• Initial assessment 30 pts

• Prolonged support 5 pts

• Suppository given 5pts

• Discharge-simple 10 pts

_____

TOTAL POINTS 50 PTS

E/M LEVEL 99282

Practice Scenario #2• A 22-year-old male presents to the ED with right hand pain,

after punching another individual during an altercation in a

bar. Initial assessment is done and his ring removed due to

swelling, using the ring cutter. The patient is clearly

inebriated and further injury were undetermined. Patient

held in observation until sobered up. C-spine precautions

were taken until further evaluations were made. Negative for

neuro or spinal injury. He was given Tylenol #3 for pain. X-

ray showed a moderately displaced fracture of the 4th

metacarpal. An immobilizing split was applied, as well as a

sling. Simple discharge instructions were given. The patient

discharged in satisfactory condition. Assessment: right 4th

metacarpal fracture, minimally displaced, reduced with

manipulation and splinting.

Practice Scenario #2• Initial assessment 30 pts

• Ring removed 5 pts

• Oral med given 5pts

• C-spine prevent 30 pts

• Discharge-simple 10 pts

_____

TOTAL POINTS 80 PTS

E/M LEVEL 99284

Practice Scenario #3• A Hispanic speaking patient came in to the wound center for

her weekly appointment to treat her chronic non-healing

ulcer of the plantar aspect of her left foot. Her son was

unable to accompany her today so an interpreter was called.

Through the interpreter we learned that on her way across

the parking lot she tripped and fell, hitting her head, right

elbow and right knee on the pavement. After a thorough

assessment, the patient was sent to Radiology for x-rays of

all three areas. The x-rays proved to be negative for

fractures. The abrasions on her forehead, elbow and knee

were cleansed, treated with an antibiotic ointment and

bandaged. Once this was completed, attention was turned

to the ulcer of her left foot. The ulcer was debrided through

the subcutaneous level, dressed and bandaged. The patient

was urged to continue to offload the affected foot with her

boot. She was discharged in satisfactory condition.

Practice Scenario #3• A Hispanic speaking patient came in to the wound center for

her weekly appointment to treat her chronic non-healing

ulcer. Her son was unable to accompany her today so an

interpreter was called. Through the interpreter we learned

that on her way across the parking lot she tripped and fell,

hitting her head, right arm and right knee on the pavement.

C-spine precautions were initiated. After a thorough

assessment, the patient was sent to Radiology for x-rays of

all three areas. The x-rays showed fractures of the both the

distal ulna and radius. All others were negative. Social

Services were consulted due to the patient being alone and

facing surgery. They coordinated with her family. After

examination by an Orthopedic surgeon in the wound center

the patient was taken to the OR for repair of the fractures.

An IV was started. Her superficial abrasions were cleansed,

dressed and bandaged prior to her transfer. She was in

stable condition.

Practice Scenario #3• Initial assessment 30 pts

• Language barrier 10 pts

• Wound cleansing 5 pts

• Simple Dressing 5 pts

• Coordination of res 10 pts

• IV insertion (1) 20 pts

• C-spine precautions 30 pts

• Admit OR 30 pts

_____

TOTAL POINTS 140 PTS

E/M LEVEL 99285

False Claims Reports• Lawsuits Involving Hospitals and Health

Systems” –Becker’s Hospital Review, July, 2011

• “Louisville, KY based Norton Healthcare agreed to pay

the federal government $782,842 in March to settle

allegations that it overbilled Medicare for wound care,

infusion and cancer radiation services by adding a

separate E&M charge that should have been included in

the basic rate. The alleged overbilling, which occurred

between Jan 2005 - Feb 2010 involved outpatient care.

The settlement is twice the amount Norton allegedly

overbilled.”

• ISSUE: Transmittal A-00-40, A-01-81 indicates there is inherent

nursing in all CPT codes. Therefore, the facility must “earn an E&M

service when done with a procedure.” Unlikely events, other

medical conditions being treated, new patient=examples.

HOPD E/M Best Practices

• If no procedure,

always look for an

E&M (99281 - 99285)

• If there is a

procedure, the E&M

must be ‘earned’

• E&M MUST be a

separate, identifiable

service

• Inherent nursing in all

procedures (PM A-00-40)

• Examples of

‘earning’ E&M in

addition to the

procedure:

– Unplanned outcome/event

– New dx, treatment, meds

– Other medical conditions

– Initial treatment

Last Thoughts on E/M Charge Capture• No separate billable services should be part of

the E&M

• Critical care (99291) - must map to a level 6

through the facility’s own system, plus be in

compliance with the CPT-4 guidelines, i.e.,

system failure, etc. If not, move back to 5

• TEST and TEST SOME MORE any changes to

the E&M leveling system

• Pull historical utilization, develop bell curve

system sorted by like diagnoses. Compare

against new proposed leveling system.

And Then There Was An Audit…• Internal self-auditing

•External assessment

•Ensure E&M criteria is

understood by staff and charted

•Can the record support the procedure AND

the separate identifiable E&M?

•Note dates of ‘improvement/changes” as part of

due diligence process

Diagnosis Codes (ICD-10-CM)

Diagnosis Codes support Medical Necessity!

• Must match the procedure or service

provided

• Must be sequenced appropriately

• Must be relevant to the date and type of

service

• Must be consistent with the providers

scope of practice

Other Providers

• What happens when a patient sees

different doctors who provide the same

service on different dates of service?

• What happens when a patient sees a non-

physician provider (NPP)?

• What happens when a patient is referred

or is a consult?– Is there a difference?

Modifiers25 - Appended to the E/M code to indicate a “Significant, separately identifiable

service by the same physician on the same day of the procedure or other

service”

51 – Multiple procedures, other than E/M services

52 – Reduced services

59 (X subsets) – Distinct procedural services, independent from other non E/M

services performed on the same day. Documentation must support a different

session, different procedure or surgery, different site or organ system, separate

incision/excision, separate lesion, or separate injury

78 – Unplanned return to OR by same surgeon following initial procedure for a

related procedure during the post operative period (global period)

79 – Unrelated procedure by same physician during the post operative period

Modifier Decision Tree

Summary

• Many different and complex factors affect

reimbursement

• Know your codes (and modifiers!)

• Know the situation

• Know your policies (NCDs/LCDs)

• Know your payer (contracts)

• Hospital specific anomalies and practices

Resources

• http://www.fcso.com

• http://www.palmettogba.com/palmetto/palmetto.nsf/DocsCat/H

ome

• https://www.novitas-solutions.com (previously Highmark)

• http://www.cgsmedicare.com/ (previously Cigna)

• http://www.ngsmedicare.com/wps/portal/ngsmedicare

• http://www.cms.gov/home/medicare.asp

• https://www.cms.gov/home/regsguidance.asp

• http://www.cms.gov/apps/physician-fee-schedule/

Thank You!

Contact info: lamartien@gmail.com

573-581-4765

CEU #