Health Information Management

Review your E/M guidelines in light of new CMS guidance

APCs Insider, July 27, 2007

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QUESTION: I have heard that CMS released some new E/M guidance in the 2008 OPPS proposed rule. Is this the case, and if so, should we modify our existing internal clinic and emergency department guidelines to conform?

ANSWER: Section IX, part C of the recent OPPS proposed rule ("Proposed Visit Reporting Guidelines") provides some guidelines from CMS for developing facility E/M visits. You can find the OPPS proposed rule on the CMS Web site: http://www.cms.hhs.gov/HospitalOutpatientPPS/downloads/cms1392p.pdf. The discussion starts on p. 502.

In the rule, CMS stated that national guidelines remain a long ways off, and in fact may not be the best solution due to the varied services performed in hospitals, and, in particular, specialty clinics. However, CMS did provide some guidance for hospitals to follow when constructing and testing their own guidelines. CMS also stated that it will "reevaluate patterns of hospital outpatient visit reporting" to ensure that hospitals properly bill for these services. Specifically, CMS stated:

Therefore, while we continue to evaluate the information and input we have received from the public during CY 2007, as well as invite comments on this proposed rule regarding the necessity and feasibility of implementing different types of national guidelines, we are not proposing to implement national visit guidelines for clinic or emergency department visits for CY 2008. Instead, hospitals will continue to report visits during CY 2008 according to their own internal hospital guidelines.

In the absence of national guidelines, we would continue to regularly reevaluate patterns of hospital outpatient visit reporting at varying levels of disaggregation below the national level to ensure that hospitals continue to bill appropriately and differentially for these services. In addition, we expect that hospitals' internal guidelines will comport with the principles listed below.

CMS then discusses six existing and five new E/M visit principles for hospitals. The five new principles include the following:

  • The coding guidelines should be written or recorded, well-documented and provide the basis for selection of a specific code.
  • The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.
  • The coding guidelines should not change with great frequency.
  • The coding guidelines should be readily available for fiscal intermediary (or, if applicable, Medicare Administrative Contractor) review.
  • The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.

To answer your question directly, review your internal E/M visit coding guidelines to ensure that they are consistent with CMS' principles. The code you assign using your guidelines should be reproducible, meaning that different people can review your documentation and arrive at the same code assignment.

Note that CMS does not require your guidelines to produce a bell-shaped curve if you place your billed E/M codes on a graph. However, providers should review their code frequencies to ensure that their guidelines do not assign all services to the highest level code. Conversely, your guidelines should not assign all services to the lowest level code. If constructed correctly, your E/M guidelines should assign services to a mix of low, medium, and high level codes, based upon the mix of patients seen at your facility in that service area.

Finally, note that the comment period to submit comments closes on September 14. The sooner you supply comments to CMS, the better.



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