Medicare Compliance & Reimbursement

Question: Does Medicare require that the E/M CPT® codes submitted for payment by the hospital and the emergency physician be identical or "match"?

Answer: No, the hospital and physician CPT® codes do not have to match. CMS has stated that Medicare does not expect a "high degree of correlation" of the E/M CPT® code levels submitted by hospitals versus those submitted by physicians. The AMA developed CPT® codes to capture physician cognitive and procedural services, and the codes were never intended to capture the utilization of hospital resources. Medicare recognizes that hospital and physician coding may have significant differences, even though the patient received services from both entities during the same encounter. The key concept is that facility and professional coding and billing are two distinct systems.