Differences of E/M Leveling in Physician-based and Hospital-based Clinics

Differences of E/M Leveling in Physician-based and Hospital-based Clinics

Hospital-based clinics have a relationship with their hospital, although it’s not usually located within the walls of the hospital. The relationship allows the hospital and the clinic to share costs and revenue; whereas, a physician-based clinic is a private physician-owned clinic where all the services and expenses are bundled into a single charge.
Clearing Up Confusion
In a hospital-based clinic, facility patient evaluation and management (E/M) levels do not have the same definition as physician E/M codes. This can be confusing because both use the same CPT® codes (99201-99205 and 99211-99215):

  • The physician’s charge represents the E/M service, and the physician chooses the appropriate CPT® code based on several components like patient history, examination, medical decision-making, counseling, etc.
  • The facility charge represents the hospital’s cost associated with caring for the patient’s face-to-face visit. This can include nursing salaries, benefits, supplies, equipment, and/or indirect and direct costs for operating the clinic. Face-to-face nursing care tasks are not separately chargeable. For example: taking a patient’s vitals, pain assessment, patient education, discharge instructions, specimen collection, and additional nursing assistance.

New Vs. Established Patients
Another piece of information in determining the correct patient level is understanding the difference in a new patient versus an established patient in a physician office versus the hospital setting. In a hospital-based clinic a new patient is a patient that has not been an outpatient or an inpatient within three years prior to the date of service of the clinic visit. This includes any type of visit, regardless of department or specialty. The Centers for Medicare & Medicaid Services (CMS) states in section 30.6.7 of Chapter 12 of the Medicare Claims Processing Manual that a new patient in a physician office is a patient who has not received professional services from the physician or physician group practice with the previous three years:

How Is the Facility Charge Translated into a Patient Level? 
Medicare states that the hospital can establish its own rules for charging patient levels; however, the charge guidelines must be consistent across all hospital-based clinics. This is accomplished by creating a nurse point tool. This tool is used to establish points for each task performed by a nurse that is not separately chargeable. At the end of the patient’s visit, the points for each task are tabulated. The patient’s total points are translated into a patient level.
For example:

  • Additional required nursing assistance = 10 points
  • Medication review = 5 points
  • Gathering vitals = 5 points

If the patient’s total points are 5-10 points their patient level would be a level 1:

  • New patient – 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making.


  • Established patient – 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services).

At the end of the visit, the patient may be charged 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity by the provider, based on the E/M components; and a 99211 based on the total number of points calculated by the nurse. To make it more complicated, the patient may also be new to the physician and an established patient for the facility patient level.
Because there is a difference in a hospital-based clinic, it’s important that the patient is aware. It’s also important that you have the correct signage in your clinic letting the patient know he is entering a hospital-based clinic. Be sure that during the check-in process the patient signs a “Sight of Service” letter at each visit. This letter explains that the patient is being seen in a hospital-based clinic and he may receive two bills, one from the physician and one from the hospital. Make sure all employees in a hospital-based clinic understand the difference, as well. This will help with possible patient questions and complaints.

Evaluation and Management – CEMC

Melissa McLawhorn
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Melissa W. McLawhorn, COC, AAPC Fellow, is the UNC health care system manager charge master. Prior to being the CDM manager, she was a charge integrity analyst for UNC Hospitals Revenue Management, and a supervisor of the UNC Hospitals Wound Healing and Podiatry Center, Vascular Interventional Radiology Clinic, and the UNC Hospitals’ endovascular clinics. McLawhorn graduated from the University of Mount Olive with a Bachelor of Arts in Visual Communications and is working on her Master’s degree in Public Health Leadership at the University of North Carolina at Chapel Hill.

6 Responses to “Differences of E/M Leveling in Physician-based and Hospital-based Clinics”

  1. Toni Turner says:

    Although I applaud your efforts to take on such a complicated topic as the difference between professional and hospital provider-based E/M leveling, I worry some points in the article only promote further confusion. It would only seem responsible to mention the fact that for coding purposes CMS consolidated the 5 E/M levels into a single G code for the facility (HOPD) back in 2014. That being the case however does not negate the expectation that the documented resources provided by the facility and involved to care for the patient continue to validate the right for a facility to report the clinic visit code (G0463) given they are otherwise compliant with the provider-based rules . The other point regarding the facility charge that was made in the article that needs clarification is the statement that “Face-to-face nursing care tasks are not separately chargeable.”. This would be true if the encounter was not being done through a provider based clinic/department (separately) and the nurse may be independently providing care to an outpatient with only a written or verbal order and not under direct supervision which is required in order to meet the eligibility of provider-based status. However, in a provider-based clinic the time the nurse spends assisting a patient in a complex transfer, assessment of a problem (eg. wound), educating patient and caregivers are all nursing care tasks that when performed and documented are considered a valid cost of resource to the facility. Some private payers do not recognize the single clinic visit G code however and may still require one of the five level codes on the claim in order to receive payment but more than likely, they are the stubborn ones that are only paying either the facility or the physicians claim anyway as they do not recognize the OPPS concept.

  2. Marg S says:

    Although the process is complicated and I am a novice and am not updated on the new codes. Based on my education, I believe: you have to review the physician and clinic based hospital policies and CMS plus other coding guidelines. You still have to account for the physician E/M plus the decision making process and the extent of the patient evaluation/visit. . I would simplify the steps, review all guidelines plus insurance billing policies and exceptions and code accordingly.

  3. Sara Bennett says:

    I am a hospital-employed nurse practitioner operating in a multidisciplinary hospital-based outpatient clinic. My sponsoring physician is employed outside of the hospital but contracted as our clinic’s medical director. These patients often see either him or I (not both of us), a dietician, exercise physiologist and a child life specialist during their visits. I am being told that I cannot bill for professional services as a non physician provider since my sponsoring physician and I are not employed by the same tax ID. I can only bill for a facility fee in some cases (only when my patient presents with a new problem), and the dietician is able to bill for medical nutrition therapy. Essentially I am providing free services and it doesn’t feel right, but I cannot find anything that specifically addresses this type of situation. Can you help point me in the right direction or help to clarify? Thanks in advance!

  4. Sabrina says:

    With facility fee billing, my main concern is the word “nurse”. Does the assessment require that an RN perform the assessment or can it be done by an LPN or CMA? This is a huge concern for our clinic. Please advise.

  5. Lynn A Kratz says:

    I had a hip injection in a hospital. I paid the hospital for procedure code 0250, 77002, 20610, J3301, and Q9967. I was then billed by the doctors office for procedure code 77002 and 20610 for a smaller amount. Is this considered double billing and if not, why?

  6. Kathy Hyatt says:

    I am having concerns of the CHF clinic charging 99212 when the nurse is documenting only . It was explained to me that because it is not a doctors office we do not have to follow the coding guidelines on the requirements to code it.
    Can someone please card any input concerning what can be coded in the E/M level and the documentation needed.
    Thanks Kathy