PROFESSIONAL OPPORTUNITIES PROFESSIONAL OPPORTUNITY | Billing and Coding | T Hospital Clinic Visits by Cindy C. Parman,T CPC, CPC-H, RCC hen a physician performs a three years prior to the current visit, be based on hospital facil- patient visit in an office or or an established patient visit (codes ity resources. The guidelines Wfreestanding center where 99211-99215) for an individual who should not be based on physician the doctor ownsACCC and/or rents the has been registered as an inpatient or resources (67 FR 66792). space, employsMember and/or contracts with outpatient within the past three years. 3. The coding guidelines should Pall staff,R andO bears allF operatingILE costs, According to the Medicare be clear to facilitate accurate payers make a single payment for Claims Processing Manual, Chapter payments and be usable for this encounter. This physician pay- 2: “The term ‘encounter’ means a compliance purposes and audits ment includes both the professional direct personal contact in the hos- (67 FR 66792). service and the technical service (in pital between a patient and a physi- 4. The coding guidelines should other words, the practice expenseACCC cian, or other person who is autho- meet the HIPAA requirements component). When the patient visit is rized by State law and, if applicable, (67 FR 66792). AperformedC in theT hospitalI ONoutpatient by hospital staff bylaws to order 5. The coding guidelines should department setting, however, the phy- or furnish services for diagnosis or only require documentation that sician bills and receives reimbursement treatment of the patient…When a is clinically necessary for patient for only the professional service. The patient has follow-up visits with a care (67 FR 66792). hospital then charges the payer for the physician in the hospital following 6. The coding guidelines should not technical services (practice expense an initial encounter, each subsequent facilitate upcoding or gaming component). A number of myths and visit to the physician will be treated (67 FR 66792). “urban legends” exist regarding how as a separate encounter for billing.”1 7. The coding guidelines should to report codes for hospital clinic The Office of the Inspector Gen- be written or recorded, well- visits. Some hospitals may even miss eral (OIG) adds: “The clinic visit documented, and provide the basis revenue from these encounters if they typically includes a history taking, for selection of a specific code. LEGALare not correctly charged. CORNERexamination, and a medical decision 8. The coding guidelines should making to resolve a patient’s present- be applied consistently across Defining a Clinic Visit ing problem.” And: “For the hospital patients in the clinic or emergency With the implementation of the to be able to charge for a clinic visit, department to which they apply. Outpatient Prospective Payment the clinic patient needs to have had a 9. The coding guidelines should not System (OPPS)N in August 2000, the face-to-face encounter with a physi- change with great frequency. Centers for Medicare & Medicaid cian, physician assistant, nurse prac- 10. The coding guidelines should be Services (CMS) issued guidelines for titioner, nurse-midwife, or visiting readily available for fiscal inter- the reporting of clinic visit codes. nurse, which includes a history taking, mediary (or, if applicable, MAC) Hospitals were instructed to Nuse the examination, and a medical decision review. existing CPT® procedure codes for making to resolve the patient’s disease, 11. The coding guidelines should CLINICALpatient visits, but establish their own condition, illness, injury, complaint, or result in coding decisions that criteria to reflect facility resource other reason for encounter.”2 could be verified by other hospital consumption. CMS states that each staff, as well as outside sources. facility is responsible for mapping Developing Internal the services provided during the Guidelines In addition, hospitals with multiple patient encounter to the different Regarding the development of inter- clinics may have different coding levels of effort represented by the nal guidelines, CMS requires that guidelines for each clinic, but these visit procedure code. Each facility is hospital internal guidelines comport sets of guidelines must measure then held accountable for following with the following principles:3 resource use in a relative manner. For its own written internal guidelines. 1. The coding guidelines should example, a level three clinic visit in Of importance, the hospital does follow the intent of the CPT® the cardiology department will use not report any consultation codes. code descriptor in that the similar resource consumption as a Instead, the hospital must determine guidelines should be designed to level three clinic visit in the oncology whether the visit is a new patient visit reasonably relate the intensity of department (even if the resources are (codes 99201-99205) defined as an hospital resources to the differ- not identical). encounter for an individual who has ent levels of effort represented The American Hospital Asso- not been registered as an inpatient by the code (65 FR 18451). ciation (AHA) and the American or outpatient of the hospital within 2. The coding guidelines should Health Information Management 10 Oncology Issues March/April 2009 As indicated, the definition of the hospital technical service is not considered to be a “nurse visit.” Association (AHIMA) jointly developed a set of proposed standardized facility E/M guidelines, which address all insurance payers (public and private). These guidelines are available online at: www.ahima. org/pdf_files/emcodingreport. pdf. From 2004 to 2005, CMS employed a contractor to evalu- ate the AHIMA/AHA guide- lines. The contractor found Table 1. APC Calculations H/BIGSTOCKPHOTO P numerous problems with the guidelines, primarily involving the need for better definitions Drug Administration Clinic Visit PHOTOGRA of terms. As part of the OPPS 250 Pharmacy 250 Pharmacy Proposed Rule for 2007, CMS 251 Generic Drugs 251 Generic Drugs posted to its website the draft AHIMA/AHA guidelines and 252 Non-Generic Drugs 252 Non-Generic Drugs also the agency’s comments 257 Non-Rx Drugs 257 Non-Rx Drugs on the guidelines. Despite the 258 IV Solutions 258 IV Solutions problems identified by the con- 259 Other Pharmacy 259 Other Pharmacy tractor, CMS stated in the 2007 270 Medical & Surgical Supplies 270 Medical & Surgical Supplies OPPS Final Rule that it believed 271 Non-Sterile Supplies 271 Non-Sterile Supplies the AHIMA/AHA guidelines were the “most appropriate and 272 Sterile Supplies 272 Sterile Supplies well-developed guidelines for 279 Other Sterile Supplies 279 Other Sterile Supplies use in the OPPS” of which the 630 Drugs Requiring Identification 630 Drugs Requiring Identification 4 agency was aware. 631 Single Source Drug 631 Single Source Drug In the 2009 OPPS Final Rule, 632 Multiple Source Drug 632 Multiple Source Drug CMS stated that it continued to see a “normal and stable” 633 Restrictive Rx 633 Restrictive Rx distribution of visit codes. The 762 Observation Room 762 Observation Room agency encouraged hospitals to 260 IV Therapy, General 700 Cast Room continue to use their internal 262 IV Therapy, Pharmacy Services 709 Other Cast Room guidelines and stated that it 263 IV Therapy, Drug/Delivery “will not implement national 264 IV Therapy Supplies guidelines prior to CY [calendar year] 2010.”5 269 Other IV Therapy Not a “Nurse Visit” As indicated, the definition of the room use, nursing services, nutrition services. Payment under any pro- hospital technical service is not con- services, social work, pain manage- spective payment system provides a sidered to be a “nurse visit.” Nurses ment assessments, and scheduling single payment for a specific service are not separately reimbursed for diagnostic tests may be included in that includes all “packaged services,” patient visits in any practice setting. the technical patient visit service per- such as use of the room, anesthesia, In all correspondence regarding formed. supplies, the services of nurses and charges for clinic visits, CMS has The April 7, 2000 Federal Register other hospital personnel, equipment stated that the facility should base describes the transition to Ambula- used, certain drugs, and various inci- the code assignment on all hospital tory Payment Classification (APC) dental services. resources used during the outpatient reimbursement under the OPPS and Table 1 is a list of revenue codes encounter. For example, items such as prohibits charging for unbundled that are included in the medical visit Oncology Issues March/April 2009 11 PROFESSIONAL OPPORTUNITIES PROFESSIONAL OPPORTUNITY As a result, it may not be possible to few, if any, additional resources. Other T report a 99211 (low level established patients may require more nursing patient visit) code whenever the attention or other hospital resources patient sees a nurse or other member to complete the drug administration. of the hospital staff. However, both the uncomplicated For 99211 services performed by administration and the more complex hospital personnel and billed as an service are reimbursed at the same “incident to” service, the documenta- Medicare APC allowance. APC T tion is expected to demonstrate the reimbursement is intended to reflect and revenues codes that are included “link” between the non-physician a “median” prospective payment and in drug administration. A review of service and the precedent physician