CMS Adopts “One Code Fits All” for Hospital Clinic Visits
This past summer, the Center for Medicare & Medicaid Services (CMS) issued notice that it was considering a radical change for emergency department (ED) and hospital clinic evaluation and management (E/M) coding. With the release of the 2014 hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System (ASC PS) final rule, that proposal becomes reality for hospital clinic visits. ED E/M coding remains unaffected—for now.
In a letter dated July 18, CMS proposed replacing the current five levels of service (based on CPT® 99281-99285 for the ED, and 99201-99205/99211-99215 for hospital clinics) “with a single Healthcare Common Procedure Coding System (HCPCS) for each unique type of outpatient hospital visit.” For example, CMS would reimburse a single ED HCPCS code, which would be based on an average of the five current ambulatory payment classifications (APCs) ($212.40, proposed).
The stated goals of the proposal were “to maximize hospitals’ incentive to provide care in the most efficient manner.” Specifically, the move was seen as a way to discourage upcoding, to remove hospital incentives to provide medically unnecessary services, and to reduce administrative burden.
The American Hospital Association, the American College of Emergency Physician, and other professional societies objected to “one code fits all” on the grounds that it did not appropriately reflect the reality of ED and clinic medicine, and that one payment for all levels would unfairly penalize inner-city EDs that treat high acuity cases. Observers also expressed concern that single-level coding would result in additional bundling of services, payment reductions, and potentially compromised patient care.
The Final Rule
CMS published the 2014 OPPS and ASC PS final rule Nov. 27. The rule does not adopt one-level coding for the ED, stating “For CY 2014, we believe it is best to delay any change in ED visit coding while we [CMS] reevaluate the most appropriate payment structure for … ED visits.” CPT®/HCPCS and APC coding for ED visits (both Type A and Type B) remain unchanged in the coming year.
Despite opposition, however, CMS has elected to collapse hospital clinic E/M services to a single level for Medicare payment in 2014, stating “we believe that the spectrum of hospital resources provided during an outpatient hospital clinic visit is appropriately captured and reflected in the single level payment for clinic visits. We also believe that a single visit code is consistent with a prospective payment system, where payment is based on an average estimated relative cost for the service, although the cost of individual cases may be more or less costly than the average.”
Under the final rule, beginning Jan. 1, 2014 all hospital clinic E/M visits—regardless of patient status (new or established) or intensity of service—will be reported using new HCPCS Level code G0463 Hospital outpatient clinic visit for assessment and management of a patient, which is assigned to new APC 0634.
Note that this change affects facility billing only, not coding for physician services.