SCOPE: All Company-Affiliated Facility and Corporate Personnel Who Work More Than 160 Hours
PAGE:1of 3 / REPLACES POLICY DATED:
EFFECTIVE DATE: January 1, 2006 / REFERENCE NUMBER: GOS.GEN.008
SCOPE: All outpatient departments of Company-affiliated hospitals paid under the Medicare Outpatient Prospective Payment System (OPPS) reporting facility Evaluation and Management Services (E/M) and all individuals performing or auditing the assignment of the facility evaluation and management (E/M) services and their supervisors including but not limited to:
Emergency DepartmentsHospital-based ClinicsOutpatient DepartmentsRevenue Integrity/ Nurse Auditors
Health Information ManagementPatient Account Services
HealthInformationServiceCenterEthics and Compliance Officers
Internal AuditE/M Approved Certified Coding Vendors
(CriticalAccessHospitals and Rural Health Clinics and Physician professional evaluation and management services are excluded from this policy.)
PURPOSE: To mandate thatall hospitals paid under the Medicare Outpatient Prospective Payment System (OPPS)implement the HCA E/M Standards and assign evaluation and management (E/M) services in accordance with the HCA E/M Standards. Use of the HCA E/M Standards for E/M assignment is mandatory; however, payer specific billing guidelines should be followed.
POLICY:
- Each OPPS hospital billing evaluation and management HCPCS/CPT codes must use the mandatory HCA E/M Standards applicable to the treatment setting (HCA Emergency Department (ED) E/M StandardsorHCA Clinic E/M Standards) to determine the facility E/M level of care reported.
- Each OPPS hospital must ensure that the point sheet used to determine the facility E/M level of care is based on the most current version of the HCA E/M Menu of Services applicable to the treatment setting (ED E/M Standards or HCA Clinic E/M Standards).
- Each person involved in the assignment of the evaluation and management level of care for OPPS hospital services is considered an E/M assigner and must complete the Company-designated E/M education.
- OPPS hospitals may only useE/M approved Certified Coding Vendors to perform E/M assignment coding reviews or E/M assignment backlog coding services.
E/M Approved Certified Coding Vendor: A vendor approved by HCA as a Certified Coding Vendor for coding audits and backlog coding that has received HCA training on the HCA E/M Standards.
See the listing on ATLAS at the following link: E/M Approved Certified Coding Vendor
E/M Assignment: E/MAssignment is the determination of the hospital’s E/M level of care for a patient based on the medical record documentation of services rendered to the patient during the visit. Both the initial determination of the E/M level of care and any subsequent determination resulting from an audit or review of the E/M level of care are considered E/M assignment and any individual performing this function is considered an E/M assigner.
E/M HCPCS/CPT Code: The Evaluation and Management services HCPCS/CPT codes used by OPPS hospitals are 92001 - 92014, 99201 - 99215, 99241 - 99245, 99381 - 99397, 99281 - 99285, 99291, and G0344.
E/M Level of Care: The E/M level of care indicates the intensity of hospital resources expendedto care for the patient during the outpatient visit. CMS requires OPPS hospitals to follow a system of mapping the E/M services provided to the different levels of effort described by the E/M HCPCS/CPT codes. The level of care is determined under the HCA E/M standards by capturing points for expended hospital resources. The points are then added and the total points are cross mapped to an E/M HCPCS/CPTcode.
E/MEducation:E/MEducation is defined as the E/M assigner training requirements outlined in the Governmental Operations Support training grid entitled Hospital- Other Training Requirements, related to the HCA E/M Standards.
Facility E/M: The hospital technical portion of the evaluation and management visit. The facility E/M does not include the physician professional component.
Medicare Outpatient Prospective Payment System (OPPS): The payment system for most outpatient hospital services. Payment for services under the OPPS is calculated based on grouping clinically and resource similar outpatient services into ambulatory payment classification (APC) groups. The OPPS applies to all hospital outpatient departments except Rural Health Clinics. Hospitals excluded from OPPS are hospitals that provide only inpatient services; Critical Access Hospitals (CAHs); Indian Health Service hospitals; hospitals located in American Samoa, Guam, and Saipan; certain hospitals in Maryland that are paid under Maryland waiver provisions; and, effective January 1, 2002, hospitals located in the Virgin Islands.
PROCEDURE:
- Initially upon implementation of this policy, and at least annually thereafter, OPPS hospitals must identify every department reporting facility E/M HCPCS/CPT codes and perform the following steps to ensure the department is using the mandatory HCA E/M Standards:
b)Ensure that all items, descriptions, and point values on the E/M level of care point sheet match the current applicable (Emergency Department or Clinic) HCA E/M Menu of Services.
c)Ensure that all items from the HCA E/M Menu of Services that describe services performed in that hospital department are included on the hospital’s E/M level of care point sheet.
d)Ensure that the hospital’s E/M point sheet does not include points for any items that are not included in the HCA E/M Menu of Services.
e)Ensure that the E/M level of care point sheet is revised in accordance with updates to the HCA E/M Standards.
f)Ensure that the patient specific E/M level of care point sheet is maintained as a business record in accordance withRecords Management policy EC.014.
- It is the responsibility of the direct supervisor to ensure that each person who is performing or auditing OPPS hospital E/M assignment receives the required hours of E/M education per calendar year.
- The facility must be able to validate compliance with this policy when requested.
REFERENCES:
CIA Continuing Education Requirements Policy, GOS.GEN.007
Record Management Policy, EC.014
65 FR 18451, Office of Inspector General; MedicareProgram; Prospective Payment SystemforHospital Outpatient Services
12/2005