January 2014
Jean C. Russell, MS, RHIT jrussell@epochhealth.com
Richard Cooley, BA, CCS rcooley@epochhealth.com
Matthew H. Lawney MSPT, MBA, CHC, mlawney@epochhealth.com
518-430-1144
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Agenda
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Visit Codes (E/M Services)
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ED E/M Changes
Clinic E/M Changes
Professional/Technical Implications
Pricing Implications
Observation Changes
Proposed changes for ProviderBased Reporting
Incident to Guideline Changes
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Visit Codes (E/M Services)
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Proposed Changes
 CMS proposed to replace the current five ED E/M
visits for type A and type B ED with a single one for
each type
 99281-99285
 G0380-G0384
 This proposal was NOT accepted in the final rule
 CMS also proposed to replace the current ten
technical clinic E/M visits with a single code
 This proposal WAS adopted
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ED E/M Proposal
 CMS did not adopt a single G code for reporting ED
E/M
 Commenters felt the range of services provided in the
ED varies too significantly to reduce all visits to the
single level
 CMS decided to not make any changes
 They are continuing to investigate
 No change to the codes
 No change to split billing
 No change to requirements for technical E/M
guidelines for the ED
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Clinic Visit E/M Codes
 New Clinic E/M
 99201 – New Pt Lvl 1
 99202 – New Pt Lvl 2
 99203 – New Pt Lvl 3
 99204 – New Pt Lvl 4
 99205 – New Pt Lvl 5
 Established Clinic E/M
 99211 – Est Pt Lvl 1
 99212 – Est Pt Lvl 2
 99213 – Est Pt Lvl 3
 99214 – Est Pt Lvl 4
 99215 – Est Pt Lvl 5
Primary service performed and reported
in a clinic is a medical visit
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Split Billing
Professional
Bill
Technical
Bill
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E/M Clinic Visit Split Billing
 Medicare expects visits to a hospital based clinic
with a hospital based “physician” to be split billed
 Prior to January 1, 2013, hospitals would report
an E/M professionally based on CMS/CPT
guidelines (either 1995 or 1997)
 And an E/M technically based on hospital
developed technical clinic E/M guidelines
Professional Bill (POS 22)
99214
Technical Bill
99212
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Clinic E/M Change
 Effective January 1, 2014 there is only one code
reported technically for clinic visits to a hospitalbased clinic:
 G0463 - Hospital outpatient clinic visit for
assessment and management of a patient
 This code replaces all of the clinic E/M codes
reported technically (99201-99205 and 9921199215)
 No change to the professional reporting rules
and codes
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Final Clinic Changes – Impact
on Beneficiary Co-Pay
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Summary of the Clinic
Change
 All clinic visits billed technically to Medicare will
be reported with the same code (G0463)
regardless of the complexity / duration of the visit
 Beneficiary co-payment for technical component
alone is close to $40 (national unadjusted); 40%
of the total
 There is no longer a differentiation technically
between “new” and “established” patient reported
codes
 The professional clinic E/M’s have not changed
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Impact of the Clinic Change
 CMS has acknowledged the challenges
faced by hospital for developing guidelines
for determining the appropriate visit level
 No longer necessary to develop Medicare
technical clinic E/M guidelines
 ED guidelines are still required
 Other payers (e.g., Medicaid DOH and
OMH) that are billed technically will
expect the 99201-99215 codes until we
are notified otherwise
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Charging Suggestions
 Suggest hospitals keep the usual ten clinic E/M
levels with their charges varying by clinic E/M (i.e.,
99201-99205 and 99211-99215) and then map these
variable charges to the single G0463 for Medicare
and (most likely) Medicare HMOs
 Charges may not be greater than Medicare APC
payment for the lower level visits (e.g., 99211)
 Should all payers be charged the same?
 Issue – Medicare has a claim suspension edit in
some cases when payment exceeds submitted
charges
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Telephone/Internet Assessment and
Management
 New E/M codes for 2014
 Not paid under OPPS or under MPFS
 99446, Inter-professional telephone/Internet
assessment/management service provided by a
consultative physician includes verbal and written
report to the patient's treating/requesting physician;
5-10 minutes of medical consultative discussion/
review
 99447 … 11-20 minutes
 99448 … 21-30 minutes
 99449 … 31 minutes or more
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Telephone/Internet Assessment and
Management
 Used when face-to-face contract may not be timely
or feasible
 Not used when the patient has been transferred to
the consulting doctor before the assessment
 May include review of medical records, diagnostic
tests, …
 Majority of the service time (more than 50%) must be
devoted to the actual verbal/internet discussion
 Single code for cumulative time
 Request for consult must be documented
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Hypothermia Tx
 99481, Total body systemic hypothermia for critically
ill neonate (per day) (List separately in addition to
primary code)
 99482, Selective head hypothermia in critically ill
neonate per day (List separately in addition to
primary code)
 Add-on codes to 99291-99292, critical care, or
99468-99469, neonate IP critical care
 Unconditionally packaged (SI N) under OPPS and
not paid under the MPFS
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Observation
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Observation
 Paid as a composite under APCs (APC status
Indicator Q3)
 Two composites in 2013 – 8002 and 8003
 Requires at least 8 hours (units of 8)
 With a high level E/M code reported the day before
or day of observation
 Without a surgical code reported the day before or
day of observation
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Observation Changes for
2014
 Significant increase in packaged services
(e.g., lab and stress tests)
 Reduction of clinic E/M codes to a single G
code (G0463)
 Required changes to observation
composites
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Extended Assessment and
Management Composite (EAM)
 In 2013 there were two composite EAMs –
8002 and 8003
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Level I Extended Assessment
and Management - APC 8002
 G0378 (8 or more units)
 Revenue code 762 (observation)
 Reported with:
 G0379 (direct referral) on the same date of service, or
 99205 / 99215 (level V clinic visit) on the same date or
day before
 Reported without a surgical (Status T) procedure
on the same day or day before
 National APC Rate (2013) = $440.70
 No diagnosis requirement
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Level II Extended Assessment
and Management APC 8003
 G0378 (8 or more units)
 Revenue code 762 (observation)
 Reported with:
 99284 / 99285 (high-level ED visit), or
High Level E/M
 99291 (critical care), or
 G0384 (high level Type B ED visit)
 On the same day or day before the observation
 Reported without a surgical (Status T) procedure on
the same day or day before
 National APC Rate (2013) = $798.47
 No diagnosis requirement
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Extended Assessment and
Management Composite (EAM)
 Effective 1/1/2014 there will be only one
composite EAM – 8009
 G0378 (8 or more units), revenue code 762
(observation) with no diagnosis requirement
 Reported with an E/M service:
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99284 / 99285 (high-level ED visit)
99291 (critical care)
G0384 (high level Type B ED visit)
G0463 (clinic E/M)
Or G0379 (direct referral to observation from physician ofc)
On the same day or day before the observation
 Reported without a surgical (Status T) procedure on
the same day or day before
 National APC Rate (2014) = $1,198.91
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Observation Payment
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G0379 – Direct Referal
 G0379 – Direct referral to observation, moved to
APC 608, payment increased to $327.85 (2014) from
$175.79 (2013)
 2012 - reimbursed as a 99211 (APC 604)
 2013 - reimbursed as a 99205 – new patient clinic
level V
 2014 – reimbursed between a level IV and V ED E/M
 Paid only when observation is not paid
 Improved reflection of the cost associated
with direct referrals to observation
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Medicare Physician Fee
Schedule Proposed/Final
Changes Impacting OPPS
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Provider-Based Clinics
 CMS acknowledges that there is an increasing trend
toward hospital acquisition of physician practices
 Resulting in increasing numbers of provider-based
clinics
 Medicare payments in these clinics are subject to
two co-pays, one for the technical component and
one for the professional component
 Generally the combination of the two results in a
higher co-pay than would be present for a free
standing physician’s office
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Provider-Based Clinics
 CMS is considering collecting information on these
types of visits
 There several proposed methods for collecting this
information:
 (1) Creating a new POS (place of service) for off
campus departments of a provider
 (2) Creating a new modifier that could be reported with
every code provided in an off campus provider based
department
 (3) Asking hospital to break out costs/charges for
these cost centers on the cost report
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Provider-Based Clinics
 CMS has received and reviewed the
comments and will let us know what they
decide
 Watch for more information in the coming
year
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Incident-To Guidelines
 Medicare now requires the compliance with
state law as a condition of payment for services
furnished incident to physician and other
practitioner services
 Would enable the federal government to recover
funds paid if services are not furnished in
accordance with state law
 Should not change anything as providers should
have already been following the applicable state
laws and state practice acts
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Questions and Discussion
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Contact Us
Richard Cooley
Phone:
Email:
518-430-1144
RCooley@EpochHealth.Com
Matthew Lawney
Phone:
Email:
845-642-6462
mlawney@EpochHealth.Com
Jean Russell
Phone:
Email:
518-369-4986
JRussell@EpochHealth.Com
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http://www.EpochHealth.com/
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CPT®
Current Procedural Terminology (CPT®)
Copyright 2013 American Medical
Association
All Rights Reserved
Registered trademark of the AMA
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Disclaimer
Information and opinions included in this
presentation are provided based on our
interpretation of current available regulatory
resources. No representation is made as to the
completeness or accuracy of the information. Please
refer to your payer or specific regulatory guidelines
as necessary.