National E/M Guidelines Still Elude Hospitals

But CMS does provide 11 points to consider when creating your policy
One issue you’ll have to continue to tackle without guidance from CMS is what kind of evaluation and management guidelines your hospital will follow. Once again in 2008, the Final Rule fails to deliver the goods on a national standard for these important services.
CMS admits that developing national E/M standards is "proving more challenging than we initially thought as we received new and expanded information from the public on current hospital reporting practices that led to appropriate payment for the hospital resources associated with clinic and emergency department visits."
To help provide direction for hospitals, however, the agency did outline 11 points in the 2008 Final Rule for developing "internal" E/M guidelines:
1. The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
2. The coding guidelines should be based on hospital facility resources -- not physician resources.
3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
4. The coding guidelines should meet the HIPAA requirements.
5. The coding guidelines should only require documentation that is clinically necessary for patient care.
6. The coding guidelines should not facilitate upcoding or gaming.
7. The coding guidelines should be written or recorded, well-documented, and provide the basis for selection of a specific code.
8. The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.
9. The coding guidelines should not change with great frequency.
10. The coding guidelines should be readily available for fiscal intermediary (or MAC) review.
11. The coding guidelines should result in coding decisions that could be verified by other hospital staff or outside sources.

The Final Rule compliments hospitals on the effort they have made to adopt internal guidelines that "reflect the scope and types of services they provide throughout the hospital outpatient system." But you shouldn’t hold your breath for national standards anytime soon: "Based on public comments, as well as our own knowledge of how clinics operate, it seemed unlikely that one set of straightforward national guidelines could apply to the reporting of visits in all hospitals and specialty clinics," the Final Rule states.
Bottom line: Each hospital’s guidelines may be different, but you should follow consistent guidelines within your own hospital.
Watch for more: Look to an upcoming edition of Ambulatory Coding and Payment Report [...]

- Published on 2007-12-20