Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 17, 2009 PDF

Plus: Many cath removals are included in E/M service.

Question: If the physician performs tube or catheter removals in a hospital exam room, should I include this as part of the E/M, or is there a more appropriate CPT code? If E/M is appropriate, should the hospital also report an E/M? If so, do the physician and hospital E/M codes need to match?

Answer: You should include tube and cath removal as part of the E/M service. Often, follow-up visits will be lower-level (such as 99212, Office or other outpatient visit ...). Inpatient E/M codes would be appropriate in inpatient cases (for example, 99231, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

Remember that if the service falls within the global period, you should not charge the E/M separately.

The hospital may report an E/M code sometimes. For example, the service may require so little work by the facility staff that it doesn't meet the hospital's criteria for even the lowest E/M code. Or if the patient has another procedure during the same encounter as the tube removal, then the hospital's E/M service would be included in that other procedure. So the physician and hospital E/M level do not have to match (although they may in some cases). A service that requires a great deal of physician effort may consume only minimal facility resources, or vice versa. The 2009 Outpatient Prospective Payment System (OPPS) final rule states that "While awaiting the development of a national set of facilityspecific codes and guidelines, we have advised hospitals that each hospital's internal guidelines that determine the levels of clinic and emergency department visits to be reported should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes."

Translation: The hospital E/M code choice should reflect the hospital's resource use, not the physician's. You may see a difference in new versus established code choices, as well. For hospitals, "Beginning in CY 2009, the meanings of new and established patients pertain to whether or not the patient has been registered as an inpatient or outpatient of the hospital within the past 3 years," the rule states.

For physicians, you choose based on whether the physician or another group physician of the same specialty has provided a face-to-face service within the last three years.