1. CDM Update – 2014 – Session 3 Evaluation and Management, Clinic and Observation Reporting
January 2014
Jean C. Russell, MS, RHIT
Richard Cooley, BA, CCS
Matthew H. Lawney MSPT, MBA, CHC,

2. Agenda Visit Codes (E/M Services) Observation Changes
ED E/M Changes
Clinic E/M Changes
Professional/Technical Implications
Pricing Implications
Observation Changes
Proposed changes for Provider-Based Reporting
Incident to Guideline Changes 2

3. Visit Codes (E/M Services)
Not updated for 2013

4. 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
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

5. 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

6. Clinic Visit E/M Codes Primary service performed and reported
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

7. Split Billing
Professional Bill
Technical Bill

8. 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

9. Clinic E/M Change
Effective January 1, 2014 there is only one code reported technically for clinic visits to a hospital-based clinic:
G Hospital outpatient clinic visit for assessment and management of a patient
This code replaces all of the clinic E/M codes reported technically ( and )
No change to the professional reporting rules and codes

10. Final Clinic Changes – Impact on Beneficiary Co-Pay

11. 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

12. 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 codes until we are notified otherwise

13. Charging Suggestions
Suggest hospitals keep the usual ten clinic E/M levels with their charges varying by clinic E/M (i.e., and ) 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

14. 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 … minutes
99448 … minutes
99449 … 31 minutes or more

15. 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

16. 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 , critical care, or , neonate IP critical care
Unconditionally packaged (SI N) under OPPS and not paid under the MPFS

17. Observation
Not updated for 2013

18. 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
Not updated for 2013

19. 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
Not updated for 2013

20. Extended Assessment and Management Composite (EAM)
In 2013 there were two composite EAMs – 8002 and 8003

21. 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 / (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

22. Level II Extended Assessment and Management APC 8003
G0378 (8 or more units)
Revenue code 762 (observation)
Reported with:
99284 / (high-level ED visit), or
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
High Level E/M

23. 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:
99284 / (high-level ED visit) (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

24. Observation Payment

25. G0379 – Direct Referal
G0379 – Direct referral to observation, moved to APC 608, payment increased to $ (2014) from $ (2013)
reimbursed as a (APC 604)
reimbursed as a – 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

26. Medicare Physician Fee Schedule Proposed/Final Changes Impacting OPPS

27. 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

28. 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

29. 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

30. 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

31. Questions and Discussion

32. Contact Us Richard Cooley Matthew Lawney Jean Russell
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Matthew Lawney
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Jean Russell
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34. CPT®
Current Procedural Terminology (CPT®) Copyright 2013 American Medical Association
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35. 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.