CMS Principles for Facility E&Ms

In 2012, CMS still allows facilities to choose their methodology for determining levels of service in the Emergency Department or clinics. They have not published “national standards” for these services and continue to monitor the submission of claims and currently are reviewing claims from 2010. Per CMS, the review continues to indicate a “normal and relatively stable distribution of clinic and emergency department visit levels’. At this time, they are not moving forward with implementation of a national system for facility E&M selection. 

Physicians working in these same areas (ED, clinics) have to follow national guidelines for determining their level of service. The physician guidelines are based on documentation involving a matrix based on 3 components, history, physical and medical decision making. Facilities, however, may choose their system as long as the services provide are medically necessary, the coding methodology is accurate, consistently reproducible and correlates with institution resources utilized to provide a given level of service. 

Various systems are available. Some are based on a point system where each service provided, such as the taking of vital signs, assistance with ambulation, etc., is assigned points. Based on the total points (services) a patent receives, an E&M level is assigned. Computerized systems are available that tallies each completed nursing staff entry and automatically selects the level of service. The American College of Emergency Physicians (ACEP) has a sample model available on their website. This model is a combination of presenting problems and possible interventions. A matrix is included with the system where the presenting problem, such as abdominal pain, is located on the matrix and then based on the interventions, CT scans, multiple reassessments, social worker intervention, the appropriate level of service is determined. Another well-known system was created by the American Hospital Association (AHA) and the American Health Information Management Association (AHIMA). The basics of this system are also found on the internet and can be adapted for individual facility use. It takes the 5 CPT E&M levels (99281- 99285) and puts them into 3 levels of care, low, mid and high. 

One major risk area with hospital systems involves “double-dipping.” An example of this would be assigning a higher level or giving more points when a Foley catheter is placed and then also billing a CPT (51702). This is an issue of concern to CMS, so verification that “double billing” scenarios are not likely to occur with your facility E&M guidelines is essential. 

Even though each system is different and can be adapted to each specific facility, CMS has provided direction in the form of general principles which facilities should review and ensure their coding system follows. These “guiding principles” were published in the 2008 OPPS Final Rule. They state the E&M coding guidelines should follow the intent of the CPT code descriptor and reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.

•  Guidelines should be based on hospital facility resources, not physician resources. 
•  Guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
• Guidelines should meet the HIPAA requirements. 
• Guidelines should require documentation that is clinically necessary for patient care. 
• Guidelines should not facilitate upcoding or gaming. 
• Guidelines should be written or recorded and well-documented. 
• Guidelines should be applied consistently across patients in the clinic or emergency department to which they apply. 
•  Guidelines should not change with great frequency.

Guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review and should result in coding decisions that could be verified by other hospital staff, as well as outside sources. 

To help ensure cooperation with the principles, facilities should have in place a mechanism for regular review of the guidelines, adoption by the appropriate departmental and hospital regulatory committees, and perform coding reviews to ensure adherence to the guidelines by the coding and billing staff. When guidelines are changed or new systems are adopted, previous guidelines should be retained with dates of use so that reviews done by outside agencies may be completed with the appropriate guidelines. For example, a review of claims from 2010 should be performed with the facility guidelines that were in place during that time period and not with the current guidelines.