Expert Panel Hatches Plan for Hospital-Friendly E/M Codes, Recommendations Sent to CMS for Federal Review

The loose guidelines for coding evaluation and management (E/M) services have caused major confusion at hospitals ever since the advent of OPPS in 2000 but a recent proposal to CMS could erase that troublesome ambiguity.
 
On June 24, the American Hospital Association (AHA) and American Health Information Management Association (AHIMA) submitted recommendations for changes to the current rules for reporting E/M services to CMS. Experts in various fields coding, health information management, documentation, billing, nursing, finance, auditing and medicine from both organizations joined together to form the Hospital Evaluation and Management Coding Panel, which has been outlining the plan since January.

The Old Way
 
Currently, five codes exist for emergency department (ED) E/M services, and 10 codes exist for clinic services. These codes map to three APCs representing low-, mid- and high-level visits, which correspond as shown in chart.
 
Because the code the physician chooses doesnt always match the amount of hospital resources used for example, a doctor may code a level four service when the facility only used enough resources to warrant a low-level visit CMS instructed facilities to come up with individual guidelines for reporting these services. And as long as you stick to the rules your facility makes, youll stay compliant and get paid.
 
Because E/M codes describe physician services not facility resources youre stuck trying to translate apples into oranges. In addition to this difficulty, many facilities worry that their self-created regulations wont pass the bar with CMS and auditors. They also worry about violating HIPAA guidelines. And because different E/M reporting systems account for different aspects of facility resources, theres no consistency across the board. So ultimately, CMS has inadequate information with which to decide on appropriate APC payments.
 
A lot of facilities are struggling with how to develop their own guidelines, says panel member Sue Prophet-Bowman, RHIA, CCS, director of coding policy and compliance at AHIMA. One advantage of moving to a new model is that many facilities that Ive talked to arent thrilled with the model theyre using, she says. Its difficult to create a system to apply codes that werent designed for facility services. Its like forcing square pegs into round holes. We hope that once people become familiar with [this new system], it will be easier and cause them less of an administrative burden than what theyre using now.

The Proposed Way
 
The panel decided to create three E/M coding models: one for ED, one for clinics and one for critical care services. For the ED and critical care models, theyve cut the five service levels down to three to coincide with the three APCs: low, mid and high. All three of the models are primarily intervention-based, meaning that the level you choose depends on the degree to which [...]

- Published on 2003-07-01