Reader Question: E/M Codes

Question: We keep hearing that the physician evaluation and management (E/M) level and the facility charge level have to be the same under APCs. Is this true?

Utah Subscriber

Answer: There seems to be a general concern regarding this issue. In certain situations, physician E/M and facility charge levels will not match. But the removal of physician diagnoses from the APC visit codes, however, allows facilities some flexibility. Regarding the emergency department, the facility level is determined by the level of nursing resources, type of room and equipment used, and time spent in patient management.

Each hospital can assign as many assessment levels as it needs. On the UB-92 billing form, these levels often are converted to a physician CPT E/M code level, and this is where the problem begins. The physicians use the E/M codes to identify the level of history, physical examination, and medical decision-making and, in some cases, time and consultation involved in caring for the patient. The E/M codes have objective criteria that must be met to use them.

A difference in service intensity level coded by the facility and the physician is not uncommon. Consider, for example, when the emergency physician sees the patient initially, but another specialist comes to the emergency department and takes over the patients care. In that case, the emergency physicians time and resources will stop, but facility resources will continue to be used as the nurses manage the patient under the care of the new specialist. In more extreme circumstances, the emergency physician bills for an outpatient service (the patients status at the time the physician turned over care), and the hospital will bill the emergency department service as an inpatient bundled into the diagnosis-related group (DRG) per the 72-hour rule. In these cases, it is impossible for the physician and facility level to match.


- Published on 2000-04-01