Clinical Coverage Topics

1. As an Outpatient Hospital facility, how would we most accurately code our emergency department and clinic visits?
2. When is it appropriate to append modifier 25 to an E&M code?
3. In the above scenario, when we do pulmonary function testing, there is a significant amount of time spent in educating the patient, preparation of the patient, etc. Would it not be appropriate to bill an E&M code to cover the costs associated with the testing?
4. Our outpatient department provides services such as audiology testing, IV administration of medications, and radiology procedures. These services require additional time and resources for monitoring vital signs, re-assessments, patient education and preparation, and extensive documentation. Is it appropriate to bill a low-level E&M code, such as 99211, to cover the cost of these services?
5. When medication management services (such as anticoagulation therapy management services) are furnished to an outpatient in our hospital outpatient clinic on the same date that the patient's medication level is tested, may we bill a low level clinic visit (99211) in addition to the HCPC code for the laboratory test?
6. Is CMS planning to create E&M codes that more accurately describe the services we provide?

1. As an Outpatient Hospital facility, how would we most accurately code our emergency department and clinic visits?

   When the Outpatient Prospective Payment System (OPPS) was implemented, providers were instructed to follow their own system for assigning the different levels of HCPCS codes. Hospitals are in compliance as long as:

   • The services are documented and medically necessary;
   • The facility is following its own system; and
   • The facility's system reasonably relates the intensity of hospital resources to the different levels of HCPCS codes.
   • The cross-walk to the level of service provided should be available upon request.

   Date Posted: 10/11/2005, Date Reviewed/Revised: 06/27/2008

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2. When is it appropriate to append modifier 25 to an E&M code?

   If a separately identifiable E&M service is provided on the same date that a diagnostic and /or therapeutic procedure is performed, then modifier 25 must be appended to the E&M code.

   Example: A patient reports for pulmonary function testing in the morning and then attends the hypertension clinic in the afternoon.

   The E&M code for the hypertension clinic visit should be reported with modifier 25 to indicate that a separately identifiable service was provided on the same date as the pulmonary function testing. This allows reimbursement for both services.

   Date Posted: 10/11/2005, Date Reviewed/Revised: 06/27/2008

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3. In the above scenario, when we do pulmonary function testing, there is a significant amount of time spent in educating the patient, preparation of the patient, etc. Would it not be appropriate to bill an E&M code to cover the costs associated with the testing?

   Routine care associated with diagnostic or therapeutic procedures, (such as education, preparation, and on-going nursing care) are incorporated into the reimbursement associated with the HCPC for the testing. It is not appropriate to bill an E&M for the routine care associated with a diagnostic or therapeutic procedures.

   Date Posted: 10/11/2005, Date Reviewed/Revised: 06/27/2008

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4. Our outpatient department provides services such as audiology testing, IV administration of medications, and radiology procedures. These services require additional time and resources for monitoring vital signs, re-assessments, patient education and preparation, and extensive documentation. Is it appropriate to bill a low-level E&M code, such as 99211, to cover the cost of these services?

   No. The activities mentioned are considered the routine care that is expected to be provided when administering the diagnostic test or procedure, and therefore, the cost would be included in the HCPC used for the service. For example, if the patient is receiving IV chemotherapy, it would be considered a standard of care to monitor vital signs, re-assess, and provide education. Therefore, it would be inappropriate to bill for these services separately with an E&M code.

   Date Posted: 10/11/2005, Date Reviewed/Revised: 06/27/2008

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5. When medication management services (such as anticoagulation therapy management services) are furnished to an outpatient in our hospital outpatient clinic on the same date that the patient's medication level is tested, may we bill a low level clinic visit (99211) in addition to the HCPC code for the laboratory test?

   Yes. When face to face medication management is provided by qualified hospital staff on the same date of the laboratory test to an outpatient in a hospital outpatient clinic, a hospital may bill CPT 99211 if the services are medically necessary and constitute a distinct, separately identifiable E&M service that is consistent with the hospital's criteria for a low level visit . For further guidance on this issue, refer to Provider Notice 03-145.

   Date Posted: 10/11/2005, Date Reviewed/Revised: 06/27/2008

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6. Is CMS planning to create E&M codes that more accurately describe the services we provide?

   Yes, CMS has created a special panel to devise new E&M codes and guidelines for emergency and clinic visits based on emergency department or clinic facility resource use, rather than physician resource use.

   Date Posted: 10/11/2005, Date Reviewed/Revised: 06/27/2008

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