Hospitals identify and follow a method for choosing the level of service
"As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates the intensity of hospital resources to the different levels of HCPCS codes, CMS will assume that it is in compliance with these reporting requirements."
There should not be a high degree of correlation between the code reported by the physician and that reported by facility .
Choosing the Level of Service
Systems for choosing the level of E/M are developed by each facility
Facilities must follow their own systems
Facility codes would not often match providers
“ New" and "established" pertain to whether the patient already has a medical record
Use 99281 for screening services in the ER when no treatment is furnished
CMS on Documentation
Facilities that use documentation to determine the level of E/M have little problem supporting the codes.
If physicians, nurses, or clerical staff assign codes without reference to documentation, routine periodic audits should be performed to ensure that documentation supports the level of service
This includes facilities that crosswalk to link their acuity levels to E/M codes.
Documentation is the final arbiter of the level of service
Inappropriate assignment of E/M codes is viewed as a compliance issue
Originally packaged item
Bundled into ER and Surgery APCs
Separate payment now allowed for 3 diagnostic categories:
Congestive heart failure
May use admitting diagnosis
Patient must be in observation for at least 8 hours and no more than 48 hours
Critical care is classified as a "significant procedure" (APC 0620) under the OPPS.
Hospitals use code 99291 to report outpatient critical care services
Used in place of a code for a medical visit or emergency department service.
Use CPT definition of "critical care" and coding guidelines
Facilities only paid for one period time with code 99291
Services usually bundled into Critical Care codes may be billed separately when furnished on the same day
Other Coding Difference
Surgery package includes all anesthesia but does not include pre- and post-operative global visits
Bill with separate E/M when provided in facility-based clinic
Do not use global maternity codes
Use “Delivery Only” codes and code for prenatal and postnatal care with E/M codes if provided in facility-based clinic
Do not use “global” codes (i.e., with interpretation and report) for services like EKGs
Use the “tracing only” codes
Inpatient Only List
Status Indicator “C”
Services that must be performed inpatient due to
Invasive nature of procedure
Need for at least 24-hours of recovery or monitoring time before the patient can be safely discharged
Performance in the inpatient setting because of underlying condition of patient
Codes removed from list due to re-evaluation and technology changes
2003 allowed payment for Inpatient Only services in outpatient for emergencies
ASC is Ambulatory Surgery Center
Free-standing outpatient surgery center not associated with a hospital
ASC list includes procedures that require ORs but not admission for procedure or recovery
Procedures not on ASC list are “out-of-scope”
Procedures that might be performed in outpatient but might require emergent admission