Practice Management Alert

Question: My physician removed a catheter in an outpatient hospital exam room. Should I include this removal as part of the E/M? If E/M is appropriate, will the hospital also report an E/M? And, if so, do the physician and hospital E/M codes need to match?

Wisconsin Subscriber

Answer: You should include simple Foley catheter removal as part of an E/M service. These follow-up visits will often be low-level visits (such as 99212, Office or other outpatient visit ...). Inpatient E/M codes would also be appropriate when your physician performs these services in the hospital (for example, 99231, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

The hospital sometimes may have the option of whether or not to report an outpatient E/M code for an outpatient ambulatory payment classifications (APC) reimbursement. For example, if the patient has another procedure during the same encounter as the catheter removal, then the hospital would not report its E/M service separately from the other procedure.

In most cases, the physician's outpatient E/M level will determine the hospital APC and any other outpatient procedure reported on the same day. The 2009 Outpatient Prospective Payment System (OPPS) final rule states that "while awaiting the development of a national set of facility-specific 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.