Wiki Use of 95/97 Guidelines for outpatient facility services

[jimbo1231]

I got into an interesting discussion with a colleague about the above. I took the position that the 95/97 guidelines were written specifically for provider services. They were not meant at all for the facility side of E&M services. It didn't make sense to me that determining whether a facility level was correct would at all be based on HPI/ROS/PE etc since these are provider services. And CMS never came up with specific facility E&M guidelines which is why they came up with G codes.

But after giving it some thought I wasn't so certain. The issue is auditing non Medicare Levels of Service. These would be clinic services not ED for which the hospital uses a version of the ACEP guidelines. Basically her argument was that with a lack of guidelines (except very general CMS guidelines) use of 95/97 guidelines would be OK. She also cited the CPT book as not specifically stating whether services are provider or facility (I stated that the whole book is for providers but hard in a way to make that argument when CMS requires the use of CPT codes except where they now have HCPSs). I think you could also argue the outcomes might be reasonable, but I'm still stuck on the 95/7 guidelines being written for physician not appropriate for facility services.

Jim S.

 

[CodingKing]

I'm still in my COC training but the first thing I was advised of the differences between CPC and COC is that E&M code level for facility is not assigned based on the DG's as it is for Professional (unless that the official policy of the facility). I do see that its suggested that ER vs Clinic set separate standards, Its also mentioned that level should be determined by resources consumed. Its the responsibility of each hospital to develop and document standards and criteria for selecting E&M code

Here's a sample document I found on a google search

http://chicago.medicine.uic.edu/Use...ile/Compliance/Tech EM Fee Training Guide.pdf

An article that may help you prove your thoughts

http://www.hbma.org/news/public-news/n_e-m-physician-versus-facility

 

[mitchellde]

Going all the way back to when APCs went into effect in August of 2000. It was stated at that time that each facility would be responsible for creating their own guidelines for the facility E&M and were provided only a few general rules. One of these was that the facility guidelines could not incorporate any part of the physician guidelines, they needed to reflect the utilization of the facility resources, which could be neither physician skill nor time.

 

[jimbo1231]

Thank you

Thank you, I completely agree. However I wonder whether some hospitals are using those guidelines as kind of default guidelines for clinic visits. But they certainly shouldn't be.

Jim