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.
- 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.
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- Differences of E/M Leveling in Physician-based and Hospital-based Clinics - September 29, 2017