Health Information Management

First E/M guidelines draft submitted to CMS

APCs Insider, July 8, 2003

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Health Information Management Division of HRM

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First E/M guidelines draft submitted to CMS

Members of an expert panel headed by the American Hospital Association and the American Health Information Management Association have proposed new E/M guidelines using a hospital staff intervention-based system that incorporates many point systems. CMS will review the guidelines and issue a final version, slated to become effective in 2004.

Here is a brief outline of the recommendations:

Three key principles:

  • The new E/M code set should accurately capture hospital resources -but not physician services - consumed during an emergency or a clinic visit.
  • Discrete hospital services that are separately billable, such as lab tests, should not be used in determining the coding level.
  • Any coding model(s) developed should be billable to all health care payers, not just Medicare.
Three coding models for three types of care:
  • Emergency department services - divided into a three-level system of intervention: low, mid, high
  • Clinic services - also divided into a three-level system of intervention: low, mid, high
  • Critical care

The panel proposes that temporary HCPCS level II codes be assigned to define E/M facility services in these three areas. The temporary codes can later be replaced by CPT 4 E/M codes.

For the complete draft, check AHIMA's web site.

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TODAY'S TOPIC: Coding repeat procedures

Question: A radiology patient is given a wrist x-ray, two views, and we use code 73100. After the doctor reviews the x-ray, he orders an additional view to make a final diagnosis. Would that x-ray be coded as 73100-76, or 73110? Also, when a procedure is repeated, under what circumstances is it appropriate to bill it?

Answer: Since your question doesn't specify why the second procedure was ordered, or precisely when, we will present two hypothetical scenerios with two different answers.

If the second x-ray additional view was performed on a different day, this case should be coded as 73100 and 73100-52. If we assume there was no intervening care or treatment between the first two views and the third one, the reasons for the views are the same as if the original order had called for three views.

We interpreted the need for the additional view to be due to the injury and the best exam required three views according to the radiologist.

In this case, the procedure is an additional view, not a repeat procedure. There is no need for a repeat procedure modifier since the same procedure was not ordered and performed on this patient on the same date of service.

A key point is whether the radiologist will dictate two reports of interpretation - one for the two-view and another for the one-view. Since the question says "He orders an additional view to make a final diagnosis," and since all three views are ordered on the same day by the same physician, we assume only one report of interpretation will be made supporting assignment of 73110.

If, however, the second procedure is a repeat of one of the first views, performed on the same day by the same physician for the same patient, it qualifies as a repeat procedure and code 73100 with modifiers -76 and -52 is appropriate.

Modifier -76 indicates a repeat procedure by the same physician. Modifier -52 is used since only one additional view is taken and there is no CPT code for one view. The two view 73100 must be billed and modifier -52 shows it is a reduced service.

It is appropriate to bill for additional exams when they are necessary to assign a diagnosis or to evaluate the results of treatment provided. There must also be a valid order, and the original exam must have been completed correctly.

It is not appropriate to bill for a repeat procedure or exam if the first x-ray is blurred, faulty, or otherwise of poor quality as the result of the technique or equipment.

ASK THE EXPERT: We are an acute care hospital with an outpatient wound care program. Should we bill autolytic wound debridement as selective debridement (code 97601) or nonselective debridement (code 97602)? Autolytic wound debridement is not an enzyme process, but it is new and the CPT manual does not address it.

Click here for the answer!

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Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.

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