Tip: Create consistent E/M guidelines
APCs Weekly Monitor, July 30, 2010
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CMS has not yet implemented national E/M guidelines for hospitals. However, it requires that every hospital’s internal guidelines meet the following principles. CMS first published these requirements in the 2002 OPPS proposed rule and most recently included them in the 2007 OPPS final rule.
A hospital’s internal E/M coding guidelines should:
- Follow the intent of the CPT code descriptor (i.e., the guidelines should reasonably relate the intensity of hospital resources to the different levels of effort represented by the code)
- Be based on hospital facility resources
- Be clear to facilitate accurate payments and be usable for compliance purposes and audits
- 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 with all patients in the clinic or ED to which they apply
- Not change frequently
- Be readily available for FI or MAC review.
- Result in coding decisions that other hospital staff and outside sources can verify
This tip is adapted from “Use internal guidelines to ensure consistent E/M coding” in the August issue of Briefings on APCs.
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