Health Information Management

Tip: Use these principles to develop E/M coding guidelines

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No national guidelines for E/M leveling exist, so facilities must develop their own.

The 11 guiding principles CMS published in its 2008 OPPS final rule indicate that the coding guidelines should:

Follow the intent of the CPT code descriptor in that they should be designed to reasonably relate the intensity of hospital resources to the different levels of effort the code represents.
Be based on hospital facility resources. They should not be based on physician resources.
Be clear to facilitate accurate payments and be usable for compliance purposes and audits. To determine whether your guidelines are clear and usable, ask someone who uses them to explain the tool.
Meet HIPAA requirements.
Require only documentation that is clinically necessary for patient care.
Not facilitate upcoding or gaming.
Be written or recorded, well documented, and provide the basis for selection of a specific code.
Be applied consistently across patients in the clinic or ED to which they apply.
Be flexible.
Be readily available for FI or, if applicable, MAC review.
Result in coding decisions that could be verified by other hospital staff members, as well as outside sources.

This tip was adapted from the article “Look to CMS, AHIMA for E/M leveling guidance” in the August issue of Briefings on APCs.

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