October 26, 2001 OPPS-E/M Coding Centers for Medicare & Medicaid Services Mailstop C4-05-17 7500 Security Boulevard Baltimore, Maryland 21244-1850 Dear Sirs: The following are comments are provided relative to a request made in the August 24, 2001, Federal Register concerning hospital, technical component evaluation and management (E/M) coding and billing. Abbey & Abbey, Consultants, Inc. Background Abbey & Abbey, Consultants, Inc. is a consulting firm providing consultation and workshops in 37 states. Our firm specializes in coding, billing, reimbursement, compliance and various payment systems. Located in Iowa, our firm assisted a number of Iowa hospitals to prepare for APG implementation. Similar services have been provided nationwide for hospitals in preparing for APCs. We have been teaching APGs and now APCs since 1992. Duane C. Abbey, Ph.D., CFP is the President of Abbey & Abbey, Consultants, Inc. CPT E/M Coding General Concerns The CPT coding system is a system developed and maintained by the American Medical Association. This system was developed by and for physicians. As a result there are a number of general concerns about using this system for APCs and more specifically for E/M coding. The guidelines, modifiers and language used to describe these codes are very much slanted toward physician coding and utilization. CMS needs to take great care in modifying the interpretation of these codes, if not the actual language used for these codes, in order to make them understandable and to provide for consistency of use across the country. Hospitals are very sensitive to compliance audits that will undoubtedly be conducted by government agencies relative to the use of these codes. Thus it is important that this guidance be explicit and timely. Considering the delays that
have already occurred in this area, any further delays could result in unnecessary compliance penalties for hospitals. Recommendation: CMS should issue a separate document providing explicit guidance for the interpretation and use of the E/M codes and associated modifiers. This guidance should clearly spell out how the coding should be accomplished so that hospital coding staff and auditing staff can use the same guidance for auditing purposes. Additionally, this guidance should not be delayed until 2003. It should be issued with all due dispatch as soon as possible. In order to provide complete and explicit guidance there are a number of issues that must be addressed. The guidance provided thus far in this area has been inadequate and has most likely led to highly disparate use and utilization of these codes across the country. It should noted that APGs bundled E/M codes when used in connection with surgical or medical procedures. CMS is to be congratulated on making the decision to break the E/M codes out for separate payment by use of the -25 modifier. At the same time, making such a decision carries with it the burden of providing guidance on how and when these codes should be used. Summary Of E/M Issues To Be Address 1. Global Surgical Package Definition - It is not possible to properly develop mappings or point systems for E/M levels without explicitly indicating what evaluation and management services are included in various surgical and medical procedures. 2. -25 Modifier The use of the -25 modifier depends entirely on having an explicit definition of a Global Surgical Package so that its use can be determined for significant and separately identifiable E/M services in connection with a surgical or medical procedure. 3. E/M Level Mapping Recognizing that CPT coding in general, and more specially E/M coding for the hospital technical component, is used to report resource utilization, there must be a mapping, point system or other algorithm used to develop the proper E/M level based on resource utilization. 4. Necessity Of Correlated Professional E/M Service CMS needs to provide clear guidance on whether it is necessary for there to be a Page - 2 -
correlated professional E/M coded and billed when there is a technical E/M component coded and billed. 5. Cross Utilization Of E/M Level Mapping Algorithms The E/M codes are used primarily in the ED and also in provider-based or hospital-based clinics, but there in concern over whether there needs to be a single, uniform mapping algorithm that must be applied to both the ED and clinics for a given hospital and/or integrated delivery system. 6. Related E/M Visits For both hospital EDs and clinics, it is not uncommon to have multiple visits for E/M services on the same date of service, and explicit guidance is needed to know when such visits are related (or conversely unrelated) in order to code and bill properly. Global Surgical Package APCs have been implemented using a 1-day window of service, i.e., the date of service. 1 This creates several considerations. For E/M services provided on the date that a surgical procedure is performed, the question is, How much of the E/M services are to be considered as a part of the surgical procedure?. Some portion of the evaluation and management should be a part of the surgery, but a very clear and concise definition of a global surgical package should be provided. With many outpatient surgical procedures, there is often a pre-surgery visit prior to the date of service on which the surgery is performed. 2 Since some portion of the evaluation and management services should be included in the surgical procedure, should these services, which are outside of the window of service, be included in the surgery? While the global surgical package question is applicable in many different settings, it is typical for the ED. The following represents some examples where further consideration is needed. Example 1 - A patient presents to the ED with a laceration on the arm. The patient is triaged by an ED nurse, the physician then performs an MSE (Medical Screening Examination) as required by EMTALA, then examines the laceration and finally sutures the laceration and sends the patient home. The question then becomes, is it appropriate for the physician (professional component) and/or the hospital (technical component) to code and bill for an E/M level along with the surgical repair? Some portion of the E/M service is a part of 1 APGs (Ambulatory Patient Groups) generally use a 3-day window of service so that any associated services can easily be bundled. 2 These visit often occur from one to four days in advance of the scheduled surgery. Page - 3 -
the surgical procedure. If the MSE is separately documented by the physician along with a more detailed examination of the laceration, then it would appear that both the physician (using the physician E/M coding guidelines) and the hospital (using a point system) could code an E/M level along with the surgical procedure. A -25 modifier would have to be used by each. The question still remains, What part of the E/M services are really a part of the surgical procedure?. The answer to this question will affect the way the E/M levels are coded. Example 2 This is the same as Example 1 except in this case the physician performs only an examination of the laceration after consulting the ED triage nurse s notes. There were no indications of any problems other than the laceration and the ED physician documents no separate general examination. Setting aside for a moment the question about meeting the EMTALA MSE requirements 3, let us consider the coding for this case. It would appear that the physician s evaluation involved only the laceration and that only the surgery should be coded since the E/M services would be a part of the surgery. However, on the hospital side there have been resources consumed (primarily the ED triage nurse and facilities) relative to the evaluation of the patient so that it appears that there should be an E/M level developed by the given point system and the -25 modifier will need to be used. Now there are two questions: What part of the E/M services is a part of the surgery? Is it proper to bill a technical component E/M service when there is no corresponding professional billing for an E/M service? Now, turning our attention to the second situation, the pre-surgery visit, the services provided in these visits typically include: nursing assessment, education, laboratory, radiology, EKG, and completing the pre-anesthesia questionnaire. The ancillary services will be billed separately 4, the preanesthesia activities are a part of the (always) bundled anesthesia services and then there is the question about the nursing assessment and educational activities performed by the nursing staff. If these same services, particularly the nursing assessment, were performed on the day of the surgery, that is, within the 1-day window-of-service, then some portion of them, if not all of them, would be considered to be a part of the surgery. However, the question remains, Is it appropriate to code and bill an 3 It is problematic that there will always be at least an E/M level on the technical side for any ED visit and most likely there should also be a professional E/M level in order to meet the medical screening examination by a qualified practitioner requirement under EMTALA. 4 These may be considered to be screening and thus not covered unless proper diagnosis codes are present. Page - 4 -
E/M level (technical component) relative to these pre-surgery visits?. Note that if there were professional services, say from a physician or other mid-level NPP (Non-Physician Provider) that bills professionally, then there would be no question about billing a technical component E/M of some sort just as there would be a professional component billed by the given provider. Thus, the questions raised here are: Can a technical component E/M level be charged for pre-surgery services that are outside the 1-day window of service? Is it proper to bill a technical component E/M service when there is no corresponding professional billing for an E/M service?. Another variation on this same theme occurs when there are unusual facility services in connection with surgical cases. Consider the following two examples. Example 3 A patient is scheduled for outpatient surgery, goes through the pre-operative procedures in the pre-operative area, and is ready to go to the surgical suites when the surgery is cancelled. Since the patient was not brought to the surgical area the use of the -73 modifier is not allowed. Resources have been consumed and, except for the fact that the patient was not taken to the surgical suites, this case would be exactly the same as a case that would pay 50% of the planned surgical procedure. 5 The question is whether or not an E/M code should be developed to address the resources utilized. Under the APC system, unless there is a code of some sort, there will be no payment at all. Example 4 An elderly patient is scheduled for a lower GI procedure and presents at 8:00 a.m. Unfortunately, the patient did not complete their pre-procedure preparations. The nursing staff takes the patient aside and, over the next three hours, prepares the patient for the procedure. The patient is then put back into the schedule and the procedure is performed. Again this is a situation where significant resources are being consumed on the part of the hospital. These services are not a routine or normal part of the procedure. It appears quite reasonable that an E/M code, using the -25 modifier, is appropriate. What is needed is a precise definition of what should or should not be included in surgical procedures relative to these unusual and extra resource utilization situations. The global surgical package definition goes beyond just associated E/M coding. For instance, there are questions surrounding the coding and billing of conscious 5 Coding guidelines allow for the highest weighted (paying) surgical procedure to be coded. Page - 5 -
sedation services (CPT=99141/99142) relative to surgical procedures both scheduled (e.g., cardiac catheterization) and unscheduled (e.g., fracture care in the ED). This service has status N under APCs and payment is bundled. However, is it appropriate to code and bill for this service in all cases? Or should this be coded and billed only when conscious sedation is typically provided as a part of the surgical procedure? It is difficult to make recommendations about a global surgical package definition for APCs without knowing exactly what E/M services were included in various surgical and medical procedures when the APC weights were developed. Since it appears that a singleton claim approach was used, then the development of both surgical APC weights and E/M APC weights would have been accomplished without any overlap. Thus the provision of an E/M service in connection with a surgical or medical procedure that is separate should be fully separately payable by using the -25 modifier. However, there has been language from CMS that would suggest that there is considered to be some inclusion of E/M services in other procedures. See for instance PM A-00-40, dated July 20, 2000. Recommendation: A Global Surgical Package (GSP) definition should be developed so that it is clear as to what E/M services are a part of a given surgical/medical procedure versus those services that can appropriately be coded and billed outside of the surgical or medical procedure coding. Additionally, the proper coding and billing of E/M services outside the 1-day window-of-service that would otherwise be considered to be a part of the surgery should also be carefully defined. -25 Modifier Utilization With the development of a Global Surgical Package definition, the use of the -25 modifier for those situations where there is an E/M service that is significant and separately identifiable will become straightforward. For instance, consider the following example. Example 5 A patient presents to a provider-based clinic to receive one of a series of injections ordered by a physician. The patient is encountered and registered. A nurse performs an assessment including an interval history including any current complaints, blood pressure, height, weight, temperature, respiration rate, and an assessment of the patient s demeanor and acuity level through discussions during the examination. The nurse concludes that the patient can proceed to have the injection. The injection is provided, the patient remains for 30-minutes, is briefly reassessed, and is then sent home. Page - 6 -
With this example it seems quite reasonable to code both an E/M level based on the nurses activities and other resources utilized along with the appropriate injection code and a J-code for the pharmacy item(s). In this case the use of the -25 modifier appears to be fully justified since because of the level of services provided. While medical necessity can be a concern, if the assessment were not performed and it was determined that the injection should not have been given, then there would be a medical malpractice suit. This same type of situation occurs with a number of different types of services. For instance, outpatient IV therapy services as ordered by a physician. One area where the use of E/M codes and the -25 modifier needs to be addressed is with chemotherapy services. In many instances there are substantial assessments made by nursing staff relative to the appropriateness of providing chemotherapy services. Interestingly enough, for freestanding physician based chemotherapy centers, this nursing assessment is allowed on an incident-to basis. Recommendation: Additional policy should be provided by CMS for the proper use of the -25 modifier relative to nursing assessment services in various settings and situations. E/M Level Mapping While additional guidance is certainly needed in this area, the development of a Global Surgical Package definition will assist in evaluating the various mappings, formulas, and point systems for being proper and appropriate. CMS should definitely develop examples of mapping systems. For instance, in the ED, if it is known exactly what E/M services are a part of a surgical or medical procedure, then adjusting and/or using a point system will be relatively easy. Since APCs pays separately for surgical procedures (and that part of the evaluation and management services associated with the surgical procedure) from the other E/M services (the MSE or Medical Screening Examination), then it is easy to remove any point accumulation associated with the condition(s) involving the surgical or medical procedure. CMS should indicate if there are any resources that should not be included in the mapping or point system. For instance, in both the ED and provider-based clinics, one of the key resources is that of nursing services and more particularly the accumulation of nursing time to put into the mapping. There are other nursing services for which there are no CPT codes, e.g. enemas or disimpactions, which also represent nursing effort and/or time. If there are any concerns on the part of CMS relative to what resources can be used and/or the way in which they are accumulated, then guidance should be provided. A simple prototype of a point system is provided as an addendum to these comments. Note that in this point system, the only services considered are those that relate to general medical assessment services and/or services that do not Page - 7 -
have any CPT/HCPCS codes. This point system has been constructed so that the fact that a patient has some sort of surgical need, e.g. a laceration or fracture, is not included in the point system since the direct E/M services associated with surgery will be paid through the APC surgical payment. As a part of this prototype, the underlying assumption is that no diagnostic conditions are considered. Only the actual services provided by and/or resources consumed on the hospital side are considered. Inclusion of diagnostic conditions could quickly become problematic since it is not known how much of the effort will be provided by the physician or physicians versus those that will be provided by hospital personnel. Thus, the use of diagnostic conditions to determine the E/M level will introduce a high degree of variability into the mapping process. Recommendations: 1. Sample mappings and/or point systems should be provided as prototypes by CMS. 2. Care should be taken to instruct hospitals to have mappings or point systems that do not include E/M services that should be a part of a surgical or medical procedure. (See Global Surgical Package Recommendation above). 3. Mappings or point systems should not include diagnostic conditions, but should reflect actual resource utilization since diagnostic conditions are not necessarily an indicator of resources utilized. Necessity Of Correlated Professional Services It needs to be clearly stated that in order for a hospital to use a facility E/M level that it is not necessary to have a correlated professional E/M level billed at the same time. As discussed above there are numerous situations where resources are being consumed by the hospital for evaluation and management services, and, at the same time, there are no services provided by a physician or other non-physician provider who would typically bill a professional component. Recognizing that CPT was developed by and for physicians, the way in which the descriptions are phrased tends to imply that only a professional provider should use these codes. For instance, CPT=99211 is the only E/M code that appears to allow for a non-physician provider. However on the hospital side, this should not be a consideration. Whatever level is developed by the mapping or point system, should be fully acceptable regardless of who has provided the service. A variation on this same theme occurs in provider-based clinics when a patient returns during the post-operative period. Page - 8 -
Example 6 An elderly patient is returning to a hospital-based clinic five days after having a minor dermatologic procedure that required suturing. The wound is examined, the dressing is changed and the patient is told to return in 3 days to have the sutures removed. For the physician this is an encounter in the post-operative period. Payment for these professional services is included in the payment for the surgical procedure(s), and typically a CPT=99024 would be coded with no charge. (Note: It is assumed the physician is not using the -54 modifier). However, on the hospital, technical component side, this is a visit consuming resources and an E/M level should be developed and billed. This visit is outside the APC 1-day window of service. In this case the concern is that there is no correlated professional billing although a professional service was provided. Recommendations: 1. There should be no requirement that a service be provided by a provider making a professional claim for a hospital to be able to bill a technical component for a service. 2. Regardless of who provides the service on the facility or technical component side, the given mapping or point system should be allowed to develop whatever level of E/M is appropriate based upon the resources utilized. Thus nonphysician staff can bill a technical component higher than a CPT=99211. Cross Utilization Of E/M Point System - The E/M level point systems, or mapping of resources utilized, involves both the ED and provider-based clinics. The development of the E/M level in these two types of settings can, and generally is, quite different. In the ED the E/M level generated by an ER physician will often be quite different from that generated by the hospital. This results from the activities of ER nursing staff and other ER support staff. Non-physician staff may perform much of the work thus increasing the level of the technical component E/M. There may be multiple providers in the ED who will separately code and bill professional E/M levels. Thus the E/M levels on the professional and technical sides of the equation will be quite different. In a general clinic setting, the technical component E/M level will correlate much more closely to the physician s E/M level. This results from the fact that the main resources utilized are nursing services and utilization of the facility. Many of the other overhead items remain relatively constant such as patient check-in and Page - 9 -
check-out, use of the waiting room, parking, etc. As the level of the physician s E/M rises, so does the use of nursing staff and the time of use of the examination room and/or other room related facilities. Additionally, within different types of clinics there may even be some variations. For instance, in dermatology clinics there will probably be a more concentrated use of nursing staff to assist a dermatologist. For general internal medicine, the physician may spend more time with each patient and require less support from nursing staff. Thus a different point system may be appropriate in different types of specialties. The main question that must be addressed is: If a hospital has provider-based clinics along with ED services, is it necessary to use the same point system, or mapping, for both the ED and the clinics? Based upon the discussion above, it seems inappropriate to have such a requirement. However, CMS needs to make it explicit that hospitals can use different mapping algorithms for clinics and the ED. For most clinics, the technical component E/M level can be correlated directly to the physician E/M level since resource utilization will correlate directly to the physician s activities in clinics. Recommendations: 1. There should be no requirement that a single, unified mapping or point system be used for both the ED and various providerbased clinics across a hospital or integrated delivery system. 2. Due consideration should be given to allowing the technical component E/M level to be the same as the physician s E/M level in clinic situations where the resources utilized correlate to the physician s E/M level. This will typically occur in providerbased clinic situations. Related E/M Visits - An associated concern for technical component coding is that of coding two or more E/M visits on the same date-of-service. It is extremely important that there be definitive guidance on when two visits are related or, conversely, unrelated. If the visits are related, then the resources utilized are all accumulated and go into a single point system or mapping to the given E/M level. If the visits are unrelated, then two or more E/M codes are developed and the -27 modifier with Condition Code G0 is used. Page - 10 -
Consider the following examples: Example 7 A patient presents to the ED in the morning with upper abdominal pain that is diagnosed as indigestion. Medicine is supplied and the patient is sent home. In the afternoon the patient presents with lower abdominal pain and appendicitis is diagnosed and medically treated. The immediate question is whether the diagnoses in these cases are related, and should thus be bundled, or are they unrelated. Example 8 A patient in the morning presents to a surgical oncology clinic relative to a recently diagnosed cancer. In the afternoon this same patient presents to a radiation oncology clinic for treatment evaluation of the same cancer. In this case there are two different encounters with two distinct clinics and thus two different registration processes. However, the diagnosis is the same for both encounters. The guidance that is needed for this issue is twofold: to distinguish between related and unrelated visits to the same clinic/ed, and then also to explicitly establish that if there are two different clinics involved, that there is no need for differentiating diagnoses. The process of defining related visits should be based on diagnosis codes, particularly the primary diagnosis codes. Unless the primary diagnoses are the same or related, then the visits should be coded and billed separately. 6 It is suggested that the primary diagnosis codes must be the same or from the same family of codes (e.g., same first three digits) in order to be related. Recommendation: Two visits should be considered to be related only if the primary diagnoses for the two encounters are exactly the same or that they are in the same family of diagnosis codes, e.g. they have the same first three digits. Summary And Conclusion Specific, clear, concise guidance is needed for E/M level technical component coding. Such guidance needs to include a Global Surgical Package (GSP) definition for APCs so that the E/M services included within a given surgical or medical procedure can be determined and not double billed through an associated, inflated E/M level. Integrated into this overall issue is the proper use of modifier -25 for separating E/M level services from a surgical or medical 6 This very same issue occurs with the 72-hour pre-admission window for outpatient services relative to DRGs. Page - 11 -
procedure. The ability of hospitals to code E/M levels when there is no associated professional service should be allowed and consideration should be given to services associated to a surgery that occur outside the 1-day window or service. This guidance is needed quickly to stave off potential compliance problems and auditing reviews by governmental agencies. Addendum Prototype ED E/M Level Point System Sample Point System For ED E/M Level Determination (Fictitious) Apex Medical Center 7 Nursing Assessments Assessments Initial & Discharge Assessments 1-2 Additional Reassements Assessments 3-4 Additional Reassements Assessments More than 4 Additional Reassements 15 Points 25 Points 35 Points 40 Points Choose One Of The Above Admission/Discharge Transfer Out Transfer In Hospital Admission Psych Admission DOA/Patient Expired Monitoring Choose All That Apply Combative/Disoriented Patient Psych Evaluation Isolation/Infectious Diabetic Monitoring Continuous Pulse Oximetry 5 Points Choose All That Apply 7 The Apex Medical Center and the Acme Medical Clinic are fictitious entities used in Dr. Abbey s workshops and books. Page - 12 -
Lab/Radiology Simple Tests By ED Staff Multiple Lab Collections Assist To or With X-Ray Assist/Monitor In X-Ray (<10 Mins) Assist/Monitor In X-Ray (10-20 Mins) Assist/Monitor In X-Ray (> 20 Mins) 15 Points 30 Points Choose Those That Apply Other Enema/Disimpactions Patient Teaching Social Services/Family Needs Other Non-Billable Procedures Consulting Physician (Specialist) Additional Consulting Physician (Different Specialty) 25 Points 15 Points 15 Points Choose All That Apply ED Level I ED Level II ED Level III ED Level IV ED Level V 0-40 Points 41-55 Points 56-75 Points 76-100 Points 101 Or More Points Notes: 1. This point system reflects only the resources utilized for evaluation and management services not otherwise associated with any surgical services provided (e.g., laceration repairs or fracture care). It is assumed that separately payable surgical and medical procedures include some level of E/M service within the payment for that service. 2. This prototype is a model only and must be adjusted for specific hospital situations. Page - 13 -
Yours very truly, Duane C. Abbey, Ph.D., CFP President, Abbey & Abbey, Consultants, Inc. Page - 14 -