3 Tips Provide a Guide to Help You Design Your Internal E/M Guidelines

Periodic self-audits will help you to fine-tune your selection criteria
If you’re hoping to skate by until CMS provides instructions on how to structure internal E/M guidelines for your facility, you’re flirting with disaster. Even by hopeful estimates, national E/M guidelines are years away from completion -- but you must take responsibility for your facility now.
Keep in mind three simple guidelines, and avoid being overwhelmed by the task.

1. Base Levels on Resource Use

In a hospital setting, you should determine the level of E/M service according to facility resources the visit consumes. This differs from the physician criteria for selecting E/M services, which reflect physician effort rather than facility costs, advises Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
"Many hospitals use a version of the ‘point system,’ for which you assign a point value to individual tasks or services (based on staff intervention or intensity, resources consumed, etc.), then total the points for the entire visit to determine an appropriate E/M level," Goodman says.
"I am partial to the point system," notes Terry Byrne, CPC, FCS, CDM specialist. "This system is objective and easily customized to any facility department."
Other hospitals have developed E/M criteria based on ICD-9-CM diagnosis codes, complexity of medical decision-making, or severity or acuity of patient’s presenting complaint or medical problem.
"Remember, however, that diagnosis-related guidelines must still relate to consumption of facility resources," Goodman reminds. "And of course, medical necessity requirements are always first and foremost. You should never try to game the system by providing more services than are necessary to treat the patient."
A few hospitals have attempted to base E/M standards on time, although these systems tend to be more burdensome to implement than the alternatives. If you choose this system, "Be aware that you can only count the time dedicated directly to care of the patient," Goodman notes. "You shouldn’t count ‘wait’ or ‘standby’ times, for instance."
Minimize the hassle: Regardless of the E/M guidelines you decide to use, the system should require only documentation that is clinically necessary for patient care. If you need additional documentation, your system won’t produce ideal results.
"Don’t develop a complicated system," Byrne confirms. "Most hospitals rely on the nursing staff to utilize the guidelines, and it is unfair to expect them to learn and know coding rules."
Note, also, that E/M guidelines "are not a replacement for medical record documentation," Byrne warns. "The guidelines are strictly a tool to translate the documentation into an E/M code."
Resource: Several organizations, including the American College of Emergency Physicians (ACEP), [...]

- Published on 2008-07-08