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
Comments To CMS – Hospital Outpatient Coding Utilization Of E/M Codes
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
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Comments To CMS – Hospital Outpatient Coding Utilization Of E/M Codes
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.
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Comments To CMS – Hospital Outpatient Coding Utilization Of E/M Codes
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
requirements3, 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 separately4, 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.
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Comments To CMS – Hospital Outpatient Coding Utilization Of E/M Codes
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.
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Comments To CMS – Hospital Outpatient Coding Utilization Of E/M Codes
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.
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Comments To CMS – Hospital Outpatient Coding Utilization Of E/M Codes
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
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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.
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Comments To CMS – Hospital Outpatient Coding Utilization Of E/M Codes
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
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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.
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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.
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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 Center7
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
20 Points
10 Points
20 Points
20 Points
20 Points
Choose All That Apply
Monitoring
Combative/Disoriented Patient
Psych Evaluation
Isolation/Infectious
Diabetic Monitoring
Continuous Pulse Oximetry
10 Points
10 Points
10 Points
5 Points
10 Points
Choose All That Apply
The Apex Medical Center and the Acme Medical Clinic are fictitious entities used in Dr. Abbey’s
workshops and books.
7
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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)
10 Points
10 Points
10 Points
15 Points
20 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
20 Points
15 Points
20 Points
20 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.
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Yours very truly,
Duane C. Abbey, Ph.D., CFP
President, Abbey & Abbey, Consultants, Inc.
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