Health Information Management

Update on facility E/M Levels under OPPS

APCs Insider, December 12, 2008

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Q. Can you update me on any changes regarding the E/M CPT codes that hospitals must use for 2009 OPPS?

A. For 2009, hospitals must continue to use their internally developed guidelines for ED and clinic E/M visits, and adhere to the 11 principles developed in 2008 by CMS. Review the 11 principles with your facility E/M criteria team to maintain the circle of compliance for this reporting requirement.


The 11 principles follow. The coding guidelines should:


1.   Follow the intent of the CPT code descriptor; the guidelines reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.

2.   Relate to hospital facility resources, not to physician resources.

3.   Be clear to facilitate accurate payments and be usable for compliance purposes and audits.

4.   Meet HIPAA requirements.

5.   Only require documentation that is clinically necessary for patient care.

6.   Not facilitate upcoding or gaming.

7.   Be written or recorded, well-documented, and provide the basis for selection of a specific code.

8.   Be applied consistently to all patients in the clinic or ED to which they apply.

9.   Not change frequently.

10. Be readily available for FI (or, if applicable, MAC) review.

11. Result in coding decisions that other hospital staff or outside sources can verify.


CMS has changed the definition for distinguishing between new and established facility E/M levels for 2009 from whether the patient has had a medical record number created within the past three years to whether the patient was registered as an inpatient or outpatient within the past three years.


APCs Weekly Monitor recommends a dedicated plan for performing detailed audits in all areas that report E/M levels. This will help ensure consistency, accuracy, and incorporation of the clinic definition that distinguished between new and established E/M levels. Monitoring modifier -25 (significant, separately identifiable E/M service by same physician on the same day of the procedure or other service), will help identify potential recovery audit contractor vulnerabilities. This is especially true for clinics which perform scheduled procedures along with medical visits on the same day


The final rule reiterated that Type A and B ED visits will continue with no changes to the definitions.

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