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Understand lack of 2008 E/M national guidelines

APCs Weekly Monitor, December 7, 2007

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QUESTION: Can you explain the E/M guidelines outlined in the 2008 OPPS final rule? Why don't we have national standards yet?

ANSWER: CMS noted in the OPPS final rule that there has been a consistent pattern, over time, of hospitals reporting visits codes distributed across all five E/M levels for clinics and EDs. In light of consistent hospital reporting patterns, CMS did not propose or finalize national guidelines for reporting visit codes in calendar year (CY) 2008. This allows hospitals to continue to use internally developed guidelines. CMS further noted that, in the absence of national guidelines, it would continue to analyze patterns for billing visits to ensure that patterns remain consistent and distributed across all five levels of visit codes. CMS provided the following 11 principles to guide hospitals in developing their internal guidelines. It is advised to maintain compliance initiatives, to review all departments' E/M criteria with the below points in ensure accuracy and reliability.

1. The hospital visit levels should reasonably relate the intensity of hospital resources to the different levels of the codes.

2. The hospital visit levels should be based on hospital facility resources, not physician resources.

3. The hospital visit levels should be clear and usable for compliance and auditing purposes.

4. The hospital visit levels should meet HIPAA requirements.

5. The hospital visit levels should only require documentation that is clinically necessary for patient care.

6. The hospital visit levels should not facilitate upcoding or gaming.

7. The hospital visit levels should be written and provide the basis for selection of a specific code.

8. The hospital visit levels should be applied consistently across patients in all departments..

9. The hospital visit levels should not change often. Annual revisions to coincide with CMS changes are appropriate.

10. The hospital visit levels should be readily available for fiscal intermediary or Medicare Administrative Contractor review.

11.The hospital visit levels should result in coding decisions that an outside source can verify.

CMS encouraged hospitals to urge the American Medical Association to publish these guidelines in the CPT Manual or other appropriate CPT resource. CMS allows a hospital to have different coding guidelines among clinics (e.g., primary care, oncology, and wound care), but that the same level code in all clinics should reflect the same level of resource use.

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