Physicians/hospitals don’t have to correlate

In the final rule on APCs, physician documentation and hospital E/M codes don’t have to correlate, notes Mason Smith, MD, FACEP, president and CEO of Lynx Medical Systems, a Bellevue, WA-based consulting firm specializing in coding and reimbursement for emergency medicine. "HCFA did not require hospitals to demonstrate that physician documentation in the clinical record supports the visit level assigned."

This eliminates a concern that the hospital’s level of service must match that assigned by the physicians, Smith explains. "It also leaves unanswered how Medicare reviewers will determine if a service level was medically necessary.’ Audit criteria for medical necessity is defined for physician services that are billed using the same CPT definitions."

Hospitals select HCPCS code

The mechanism for designating the correct HCFA common procedural classification system (HCPCS) code is left up to the hospital to decide, based on intensity of service, says Jeffrey Bettinger, MD, FACEP, member of the Dallas-based American College of Emergency Physicians’ reimbursement committee and co-chair of the Florida College of Emergency Physicians’ medical economics committee. "An expert advisory panel will look further into possible methods of better identifying underlying resources utilized, especially nursing services," he says.

The hospital will assign an HCPCS code for each service rendered. Currently, the hospitals are expected to supply this code, but it will now be a requirement, says Bettinger. "The Medicare intermediary will cross-reference the HCPCS code to the corresponding APC, which will determine payment."

For basic services in the ED, there will be four APCs that correlate to six HCPCS codes, as follows:

• 99281 (problem-focused decision making) and 99282 (expanded problem-focused low medical decision making) will cross-reference to APC 610 (low-level emergency visits).

• 99283 (expanded problem-focused moderate medical decision making) will cross-reference to APC 611 (mid-level emergency visits).

• 99284 (detailed medical decision making) and 992-85 (comprehensive medical decision making) will cross- reference to APC 612 (high-level emergency visits).

• 99291 (critical care services) will cross-reference to APC 620 (critical care).

The hospital can list only one of those HCPCS codes, in addition to other billable HCPCS codes that cross-reference to other APCs. HCFA expects the hospital to have an internal system of choosing HCPCS codes 99281 through 99285 and 99291 based on intensity of service, Bettinger explains. "This system need not correlate with the choice of physician service CPT codes."

The physician’s choice of a CPT code might have no correlation with the HCPCS code designated by the hospital, he notes. "Overall, I am happy with the final rule, as I had concerns that hospitals would have widespread undercoding, which could potentially be used by HCFA to question the CPT coding of the corresponding physician services."

The potential existed to cross-reference the two codes and possibly downcode the physician’s CPT code, Bettinger explains. "By de-linking the hospital’s HCPCS code and the physician CPT code, the potential to challenge physician coding is diminished," he says.

Lack of correlation between the hospital’s HCPCS coding and the physician CPT coding will diminish the importance of physician documentation, he notes. "Probably nursing time will be a major determinant, along with the amount of ancillary services utilized."

Hospitals will develop unique systems for mapping services to different visit levels, says Caral Edelberg, CPC, CCS-P, president of Medical Management Resources, a Jacksonville, FL, emergency medicine coding and consulting firm specializing in financial reimbursement. "Facilities will be expected to develop and comply with their own facility’s unique levels, and the crosswalk of these levels to the appropriate HCPCS code[s]," she explains. "HCFA expects assurance that each facility will follow its own established criteria, and those criteria are expected to represent the intensity of service at the different levels of HCPCS codes."

For more on ambulatory payment classifications, contact:

Jeffrey Bettinger, MD, FACEP, Team Health, Financial Services Division, 100 N.W. 70th Ave., Plantation, FL 33317. Telephone: (954) 584-1000, ext. 2438. Fax: (954) 377-2670. E-mail:

Caral Edelberg, CPC, CCS-P, Medical Management Resources, 9550 Regency Square Blvd., Suite 1200, Jacksonville, FL 32225. Telephone: (904) 725-4889. Fax: (904) 724-1948. E-mail:

Mason Smith, MD, FACEP, Lynx Medical Systems, 15325 S.E. 30th Place, Suite 200, Bellevue, WA 98007. Telephone: (425) 641-4451. Fax: (425) 562-4860. E-mail: Web: www.