Pulmonology Coding Alert

Question: If the physician performs tube or catheter removals in a hospital exam room, should I include this as part of the E/M? If E/M is appropriate, will the hospital also report an E/M? And, if so, do the physician and hospital E/M codes need to match?

Wisconsin Subscriber

Answer: You should include tube and catheter removals as part of an E/M service. Often, follow-up visits will be lower-level (such as 99212, Office or other outpatient visit ...). Inpatient E/M codes would be appropriate in inpatient cases (for example, 99231, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

The hospital sometimes may have the option whether or not to report an outpatient E/M code for the outpatient ambulatory payment classifications (APC) payment. For example, if the patient has another procedure during the same encounter as the tube removal, then the hospital cannot report its E/M service separately from the other procedure.

In most cases, the physician's outpatient E/M level will determine the hospital APC and any other outpatient procedure reported on the same day. Some services may be bundled together, however, as in physician reporting.

The 2009 Outpatient Prospective Payment System (OPPS) final rule states that "While awaiting the development of a national set of facility-specific codes and guidelines, we have advised hospitals that each hospital's internal guidelines that determine the levels of clinic and emergency department visits to be reported should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes."

Translation: The hospital E/M code choice should  reflect the hospital's resource use, not the physician's. You may see a difference in new versus established code choices, as well. For hospitals, "Beginning in CY 2009, the meanings of new and established patients pertain to whether or not the patient has been registered as an inpatient or outpatient of the hospital within the past 3 years," the rule states.

For physicians, choose a new or existing patient designation based on whether the physician or another group physician of the same specialty has provided a faceto- face service within the last three years.