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Hospital Based Coding Question

  1. Default Hospital Based Coding Question
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    I am looking for assistance with hour an hosptial based facility uses E/M coding when there is no physician present. Per CMS, the FR states that a hospital can use "hospital resources" based on the descriptor in the CPT book. Well the CPT book states "physician face to-face or other qualified health provider. So does this mean the other qualified health provider is only one that can "bill for services" or documents nurses notes (RN). Help!

    Need for proper infusion and -25 E/M coding

  2. Default Yes, its okay to bill E&M with no physician face to face
    Here are some guidelines with a reference. There doesn't have to be physician face to face to bill a facility E&M. This is from Trailblazers, but it is CMS guidance and the reference is straight from CMS.

    Under the OPPS, unless indicated otherwise, CMS does not specify the type of hospital staff who may provide services in hospitals because the OPPS only makes payment for services provided “incident to” physicians' services. Hospitals providing
    services “incident to” physicians' services may choose a variety of staffing configurations to provide those services, taking into account other relevant factors such as state and local laws and hospital policies.

    Facilities should code a level of service based on facility resource consumption, not physician resource consumption. This includes situations where patients may see a physician only briefly or not at all.

    If a visit and another service are also billed, the visit must be separately identifiable from the other service since the resources used to provide non-visit services including staff time, equipment, supplies, etc, are captured in the line item for that service.

    Billing a visit in addition to another service merely because the patient interacted with hospital staff or spent time in a room for that service is inappropriate.

    All services furnished must be medically necessary and documented.
    CMS Pub. 100-02, Chapter 6, Section 20.5.1
    CMS FAQ 8810
    OPPS Final Rule published November 1, 2002 (Vol. 67, No. 212, pages 66790–66793)

    Susan Tompkins, CPC, RN, JD

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