Health Information Management

Tip: CMS proposal could change E/M dramatically

APCs Insider, August 16, 2013

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Evaluation and management (E/M) coding and reimbursement for hospital outpatients could change dramatically if CMS finalizes its proposal to replace current E/M CPT® codes with three G-codes.

Currently, hospitals report different E/M codes for different levels of services in different settings:

  • New patient clinic visits (CPT codes 99201-99205)
  • Established patient clinic visits (CPT codes 99211-99215)
  • Type A ED visits (CPT codes 99281-99284)
  • Type B ED visits (HCPCS level II codes G0380-G0384)

Coders select visit levels based on documentation of history, examination, and medical decision-making. Each facility or office creates its own guidelines for determining what constitutes each level of visit according to CMS’ 11 principles for creating the criteria.

Under the proposal, CMS would replace all of these codes with three new HCPCS G-codes. The G-codes would be assigned to three different visit APCs:

  • One APC for all clinic visits
  • One APC for all Type A ED visits
  • One APC for all Type B ED visits 

The proposal would reduce the number of codes from 20 to three and would eliminate the sometimes subjective application of visit criteria. It would also reduce the documentation required from providers because coders would no longer need to assign a level.

This tip is adapted from “Significant changes proposed for evaluation and management coding” in the September issue of Briefings on APCs.



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