Health Information Management

Coding an E/M level v. a CPT code

APCs Insider, May 28, 2004

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QUESTION: Regarding your May 21 article on billing a clinic visit and hospital visit on the same day, would the same answer-that the hospital can bill an E/M level for a service that has no CPT code-be applied if the patient was sent to have a service there is a CPT code for? For example, if a clinic patient was sent to the hospital for an injection, would the hospital be allowed to bill for both the CPT code and a low-level E/M service? Does the fact that the patient may only see nursing staff and not the physician at the hospital have any bearing?

ANSWER: Here is how a hospital distinguishes between coding an E/M level and a CPT code for a service.

First, the patient and service must meet certain criteria:

  1. The patient is a registered outpatient of the hospital in a provider-based location, and the visit meets the definition of an outpatient encounter at 42 CFR 410.2. "Encounter" means a direct, personal contact between a patient and a physician or other person who is authorized by state licensure law and, if applicable, by hospital or critical access hospitals (CAH) staff bylaws, to order or furnish hospital services for diagnosis or treatment of the patient.
  2. Services are medically necessary.
  3. Services are properly documented in the medical record.
  4. The hospital has protocol for mapping resource utilization to one of the E/M visit levels.
If the patient and service meet the above criteria, code as follows:

  • If a CPT/HCPCS code exists for the specific service, it should be billed as long as other coverage, medical necessity, and documentation requirements are met.
  • If a CPT/HCPCS code does not exist for the service and the service meets the definition of a visit/encounter and is performed by personnel licensed and credentialed under the state to perform it, the service may be billed using an E/M code.
  • Finally, to code both E/M code and a CPT/HCPCS code for the specific service on the same day, the following conditions must be met and accompanied by complete, comprehensive documentation:

    • The patient's condition requires a significant separate E/M service above and beyond the procedure performed
    • The service is beyond the usual pre- and post-care associated with the procedure
    • A separate history was taken, a separate physical was performed, and a separate medical decision was made and is documented in the medical record

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