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Briefings on APCs, October 2008, Questions on E/M for hospital-based outpatient clinics

Questions on E/M for hospital-based outpatient clinics

Editor’s note: Susan Garrison, CHCA, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPAR, executive vice president of healthcare consulting services at Magnus Confidential in Atlanta, and Sarah Goodman, MBA, CPC-H, CCP, FCS, president, CEO, and principal consultant at SLG, Inc., in Raleigh, NC, answered the following questions for listeners of the June 25 HCPro audio conference, ”Hospital-Based E/M Coding.”


Q. We have nonemployed physicians who see patients in our facility. In some cases, they don’t have a nurse perform vitals. The medical record is not ours; it is the physician’s.

Can we report a facility charge for the room? The only resources these visits use are indirect costs such as electricity, malpractice, and other overhead.


A. Facilities that employ physicians are responsible for coding and billing the facility and the professional fees. Facilities that do not employ physicians should not bill their professional fees.

Regardless, if you bill for the facility, and the physician provides services within your facility, you should bill for overhead and document these services. Your costs include the bricks and mortar as well as the staff. If the physician performs a procedure, you’ll need to bill for the technical component since he or she used your facility (this practice follows that of an outpatient hospital surgery, in which the hospital codes for the surgery even though a physician performs and bills the procedure). I would also propose that, as you develop your E/M system, you should determine your base cost (indirect and direct) per patient, even when your clinical staff has no direct involvement, and make that part of your driver since the physician is using your overhead.


Q. For some time, the head of our radiation oncology department has requested that I set up an E/M code for billing the time the department head spends educating patients. From my viewpoint, our charges include education. Can you settle the dispute?


A. Education alone does not warrant a separate E/M service. However, it is customary to establish faci- lity E/M codes to capture the technical component of the radiation oncologist’s evaluative and consultative visits with patients since they involve facility space and resources.


Q. When a patient comes in for a wound debridement, the physician dictates a note that states the medical necessity of the debridement. The nurse is present, but the physician does not mention it in his note. The nurse has a check box that states vitals and any new signs or symptoms. Does the nurse need to document this information in the chart and use the check box? Does the physician need to document that the nurse assisted with the procedure in order for the facility to receive reimbursement?


A. Since the patient is presenting for a specific procedure (wound debridement) that uses facility space, routine supplies, and possibly staff resources, the facility should bill for the technical component of the procedure. A separate E/M is not appropriate in this scenario, even if the nurse takes vitals and documents signs and symptoms.


Q. An outside physician documents an order for daily dressing changes at our wound care center. The patient presents, and an RN removes, cleans, and changes dressings daily for five days. Can we charge for a professional 99201 E/M for the nurse’s time, or only an E/M 99211 facility charge?


A. In this scenario, there is no professional component, only a facility one. Unless the RN performs nonselective debridement, which would warrant code 97602 instead, you would likely report 99211 in this case, as long as the physician order and nursing documentation supports it.


Q. In a wound care clinic where a wound care employee is actually a licensed therapist (e.g., a physical therapist), can he or she bill an E/M like any other staff member as long as the patient does not have an established rehab plan of treatment? Since a therapist cannot bill for nonselective debridement, can he or she bill a low-level E/M? I cannot find anything in the literature that restricts a therapist from billing an E/M. My feelings are that the therapist is functioning under a wound care job description and does not use his or her PT license to perform these services.


A. You should not report an E/M code in lieu of a more appropriate code. You can bill nonselective debridement (code 97602) under revenue code 042X and 043X or use the site of service, such as 0761 (treatment room).

Do not report it with the -GP or -GO modifier if a therapist performs the service, since he or she does not perform the service under a therapy plan of care. Code 97602 has a status indicator of T and is reimbursable under OPPS.

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