Controversy: Clinic Visits, Evaluation & Management (E&M) Services, and Minor Procedures

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Although the coding regulations (pertaining to clinic visits, evaluation and management [E&M] services, and minor procedures) have not recently changed, controversy about these topics continues between hospital-owned outpatient wound/ulcer management provider-based departments (PBDs), the physicians/qualified healthcare professionals (QHPs) who work in the PBDs, the revenue cycle team, and internal/external auditors. This month’s Consultation Corner should end some of these controversies.  

Scenario

Following are the top 5 controversies that this consultant had to address this quarter:

1. The hospital hired an outside auditor to review claims for all the departments of the hospital. After reviewing the claims of the PBD and the physicians/QHPs, the auditor advised them to report the “new” patient clinic visit and E&M codes any time they saw a patient that was “new” to them. The PBD, physicians, and QHPs thought that advice was wrong—were they correct?

2. An outside auditor, hired by the hospital, advised the PBD and the physicians/QHPs to report the “new” patient clinic visit and E&M codes when a patient, who was discharged with a healed wound, returned several months later with a new wound. The PBD, physicians, and QHPs thought that advice was wrong—were they correct?

3. When the physicians/QHPs performed selective debridements, they reported an E&M code (instead of the selective debridement code) because the E&M code had a higher Medicare allowable rate on the Medicare Physician Fee Schedule (MPFS) than the selective debridement code. The PBDs reported the selective debridement code because that was the procedure performed and it had a higher Medicare allowable rate on the Outpatient Prospective Payment System (OPPS) fee schedule than the clinic visit code; the PBDs think the physicians/QHPs should also report the selective debridement code. Who is correct?

4. When a procedure, such as debridement of subcutaneous tissue, was performed on the patient’s first visit to the PBD, the physicians/QHPs and the PBD always reported a clinic visit/E&M code and the subcutaneous tissue debridement code. The compliance officer does not think a clinic visit/E&M code is always justified. Who is correct?

5. A large health system has 6 different outpatient wound/ulcer management PBDs. Five of the PBDs always charge the same amount for the clinic visit code, no matter whether the patient was new or established, and no matter how much work and resources were used during that encounter. The sixth PBD charges 10 different rates for the clinic visit code. The health system wants the sixth PBD to align with the other 5 PBDs, but the sixth PBD does not want to change its process because it believes it is correct. Who is correct?

Facts to Consider

Scenario 1: A patient is considered “new” to the PBD if the patient has not been registered for any service in the entire health system for the past three years. A patient is considered “new” to a physician/QHP if the patient has not received services from a physician or QHP of the same specialty and subspecialty who belongs to the same group practice within the last 3 years.  

Scenario 2: A new wound is not justification to report a “new” clinic visit code or a “new” E&M code. See scenario 1 above.

Scenario 3: When a procedure is performed, the procedure code should be reported. Because physicians/QHPs are paid by a different Medicare payment system (the MPFS) than the PBD (the OPPS), their financial incentives do not always align.

Scenario 4: When a minor procedure is performed, an E&M/clinic visit code should only be reported when a significant and separately identifiable E&M service (unrelated to the decision to perform a minor surgical procedure) is performed by the same physician/QHP on the same day the procedure is performed. The National Correct Coding Initiative Policy Manual for Medicare Services states that “The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”¹

Scenario 5: When the OPPS was implemented, the Centers for Medicare & Medicaid Services (CMS) instructed PBDs to use the E&M codes 99201–99215, but not to use the American Medical Association’s guidelines for the codes. Instead, the CMS instructed the PBDs to develop a mapping system (and a policy and procedure for its use) for the codes based on the resources that each PBD uses for each level of new and established patient clinic visits. Therefore, the PBDs had a different charge on their Charge Description Masters for each of the 10 clinic visit codes.  

Several years ago, the CMS introduced the PBDs to only report one clinic visit code (G0463) for each Medicare encounter. The CMS determined the OPPS allowable rate based on the average of all the charges that PBDs had submitted on their claims for 99201–99215 over the prior two years. Because the CMS never told the PBDs to stop using their mapping system to 99201–99215, PBDs should still be using their mapping system to 99201–99215 and to the appropriate charge. Then, for the Medicare fee-for-service patients, they should report G0463 with the charge that was affiliated with the appropriate clinic visit code. That way the CMS will see that the PBDs still perform various levels of clinic visits that require various amounts of resources. In fact, if the PBDs only report G0463 with one charge, an unintended consequence will most likely occur: the OPPS allowable rate for G0463 will decrease.

Consultation

Each time this consultant was contacted to address these controversies, I always reminded all the stakeholders that they should refer to the regulations.

• In scenarios 1 and 2, the PBDs, physicians, and QHPs were placed in a defensive position with their administration. I advised them to do 2 things: 1) present the “new” patient regulations to their administration, and 2) recommend that their administration request documentation from the outside auditor to support the auditor’s advice. The administration was surprised to learn that the auditor could not support their advice. Therefore, the PBDs, physicians, and QHPs were correct.  

• In scenario 3, I reminded all the stakeholders 1) that you should not select codes by the payment rates you like, and 2) that the financial consequences of submitting false claims should be sufficient reasons to report the work that was actually performed. I also referred them to the January 2020 Consultation Corner, which addresses this exact topic.²

• The PBDs were correct to report the selective debridement code, but they should only be reporting that code because it was the procedure the physicians/QHPs performed—not because the selective debridement had a higher allowable rate than the clinic visit. Likewise, the physicians/QHPs should report the selective debridement code, because that is the procedure they performed, even if this payment rate is less than the payment rate for an E&M.

• In scenario 4, the compliance officer was correct. I always remind stakeholders that PBDs, physicians, and QHPs rarely perform a significant and separately identifiable E&M service (unrelated to the decision to perform a minor surgical procedure on the same day the procedure is performed). Therefore, the number of claims with an E&M and modifier should be a rare occurrence.

• In scenario 5, the sixth PBD is correct. This is a perfect example that “following the crowd or the persons with the loudest voices” is not always correct. When the sixth PBD proved to the health system administration that the CMS never told the PBDs to stop using their mapping tool or to stop attaching 10 different charges to G0463 (based on the resources used), the administration required the other 5 PBDs to return to using their clinic visit mapping tools and return to attaching the appropriate charge to G0463.

Summary

Because these controversies continue to be widespread, all readers should not assume that their current practices are correct. If any of these scenarios pertain to your situation, now would be a great time to refine your processes. In some instances, this refinement may reduce your payment rate, but you should never be collecting payment that you should not have reported. Keep in mind that repayments, especially triple damage repayments, are painful!

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net.

1. National Correct Coding Initiative Policy Manual for Medicare Services: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index. Last accessed June 20, 2020.
2. Schaum, KD. Don’t select codes by the payment rate you like. Today’s Wound Clinic. 2020; 14(1); 30-31.