Health Information Management

Q/A: Should we report low-level E/M for all infusion patients?

APCs Insider, May 10, 2013

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Q: We routinely bill a low level E/M for all patients coming into our infusion clinic. This is to cover the resources for registration, education, room set up, etc. We have a tool that maps a regular visit to the low level code – typically 99211. This doesn’t require the presence of a physician according to the CPT® definition. However, one of our nurses went to a seminar and came back saying we shouldn’t be reporting this for everyone. Do you have any insight?

A: CMS has issued guidance concerning the reporting of evaluation and management (E/M) visits since the beginning of the OPPS. All of the guidance notes that to report a E/M visit code in addition to a scheduled procedure, there must be something separate and distinct about the situation that warrants an E/M. All procedures include resources to register the patient, show them to a room, assess the patient condition prior to the procedure, etc., as this is a standard of care and required for the safety of each patient, as well as to provide a baseline. These resources should be included in the charge for the procedure.
 
CMS published FAQ 8810 in July 2009 and noted:
 
Billing a visit code in addition to another service merely because the patient interacted with hospital staff or spent time in a room for that service is inappropriate. A hospital may bill a visit code based on the hospital’s own coding guidelines, which must reasonably relate the intensity of hospital resources to the different levels of HCPCS codes. Services furnished must be medically necessary and documented.
 
The guidance provided below is found in the Federal Register from November 11, 2002, in the OPPS final rule for CY 2003, and specifically notes for drug administration services (p. 66793 – 66794):
 
 
 
Comment: One commenter asked CMS to clarify proper billing for E/M services when a visit and another service, such as chemotherapy, have been provided.
 
Response: If a visit and another service is also billed (that is, chemotherapy, diagnostic test, or surgical procedure) the visit must be separately identifiable from the other service. This is because the resources used to provide non-visit services (including staff time, equipment, supplies and so forth) are captured in the line item for that particular service. However, billing a visit in addition to another service—merely because the patient interacted with hospital staff or spent time in a room for that service— is inappropriate.
 
Based on the guidance provided, it is recommended to review your current process and insure that the resources for the evaluation are built into the procedure for which the patient is scheduled and that is performed.
 
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.



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