Facility Evaluation & Management and the 2011 OPPS Proposed Rule

Hospitals have been struggling since the inception of the Outpatient Prospective Payment System (OPPS) back in 2000 with CMS’s instructions for hospitals to develop internal hospital guidelines to determine what level of visit to report for each patient. General guidelines have been provided over the course of the last 10 years such as:

• Each hospital’s internal guidelines should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.
• The full range of CPT codes should be used - CPT codes 99201-99205 for new patients and 99211-99215 for established patients are used (note that there have been several revisions over the years to the meaning of new and established). In the provider-based clinic setting and CPT codes 99281-99285 are used in the Emergency Department setting.
• That just because the patient interacted with hospital staff or spent time in a room, does not in itself justify the assignment of a facility E/M code.
• That it is possible that various specialty clinics in a hospital could have their own set of guidelines, specific to the services offered in those specialty clinics. However, if different guidelines were implemented for different clinics, hospitals should ensure that the guidelines reflected “comparable resource use at each level to the other clinic guidelines that the hospital might apply.”
• CMS stated that they were concerned about counting separately paid services (for example, intravenous infusions, x-rays, electrocardiograms, and laboratory tests) as ‘interventions,’ or including staff and their associated ‘staff time’ in determining the level of service. CMS “believed that the level of service should be determined by resource consumption that is not otherwise captured in payments for other separately payable services.”

I believe all of us in this industry have been looking forward to some standard facility E/M definitions from CMS as well as a specific code set separate from having to use the physician codes. In last years 2010 Rule, CMS stated that they understand that it would be disruptive and administratively burdensome to other hospitals that have successfully adopted internal guidelines to implement any new set of national guidelines. With this statement I am not sure if we will ever have a unique set of facility codes and guidelines.

So again in the 2011 OPPS Proposed Rule, CMS continues to not provide a set of national facility E&M codes definitions. In addition, they continue to believe that distinguishing between new and establish is not significant for facilities to determine.

In this intense environment now of Regulatory Audits – RACs, MIPs, OIG, etc., and with CMS mentioning RACs in last years OPPS Rule in relation to facility E&M codes, it is more important than ever for facilities to submit their comments on these topics to CMS and continue to explain to them the importance of establishing a facility specific code set and national coding guidelines for facility E&M codes.

Written by Kim Charland, BA, RHIT, CCS