Evaluation & Management vs. Hospital Owned Outpatient Provider-Based Department Clinic Visits

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

If you had an opportunity to listen to the webinar entitled “2021 Mid-Year Reimbursement Reports: A Live Discussion Series,” that Jolayne Devers and this author presented on July 28, 2021, you know that the topic was Wound Care Audits Have Resumed: Are You Prepared? The attendees submitted many excellent questions during the webinar and sent many more emails to this author following the webinar. To accommodate the high volume of questions, this author promised to address the topics and questions in this and future Business Briefs columns.  

One of the topics that generated many questions and follow-up emails was “Physician/qualified healthcare professional (QHP) evaluation & management (E/M) services are different than hospital owned outpatient wound/ulcer management provider-based department (PBD) clinic visits.” Following are some of the misperceptions that precipitated the questions.

•    Our PBD always reports the same clinic visit level as the level of E/M services reported by the physician/QHP.

•    Our hospital system says that our PBD should never report clinic visits because the PBD is procedure based.

•    When a physician does not see the patient, and the wound care nurse assesses the wound, our PBD always reports 97602, rather than a clinic visit.

•    Now that the new E/M guidelines are in place, we are billing for our PBD visits based upon the time spent by the wound care nurse.

•    Our PBD only has one charge affiliated with G0463.

As you can see, confusion surrounding E/M codes and guidelines for physicians/QHPs, and clinic visit codes and guidelines for PBDs still exist. Let’s address these questions/issues with three important facts.

1.    The new 2021 E/M guidelines for 99202–99215 only apply to physicians and QHPs who perform these services in their offices or in an outpatient or other ambulatory facility, such as in the PBD. These new E/M guidelines do not apply for similar services performed in hospitals, nursing facilities, emergency departments, or in observation care.

Because the new E/M guidelines only apply to physicians and QHPs. PBDs should not report their clinic visit codes based on the amount of time the wound care nurse spends with their patients.

However, the elimination of 99201 by the American Medical Association does apply to PBDs. Effective January 1, 2021, the PBDs should have eliminated 99201 from their clinic visit level mapping tools, from their Charge Description Masters, and from their charging systems. To align with their revised clinic visit level mapping tools, the PBDs should have updated their clinic visit level policies and procedures.  

In addition, the PBD should have worked with their electronic healthcare record manager to 1) adjust to the revised PBD clinic visit mapping tool, and 2) adjust to the new E/M guidelines for the physicians/QHPs who work in the PBD.

2.    When the Centers for Medicare & Medicaid Services (CMS) implemented the outpatient prospective payment system (OPPS) in 2000, they instructed the PBDs to borrow the E/M codes 99201–99215, but to create their own mapping tool based on the resources needed to provide each level of clinic visit. Therefore, the PBDs 1) created unique mapping tools based on the services that they provided and supported, 2) wrote policies and procedures for their employees and internal/external auditors to follow and 3) assigned different marked-up charges for each of the 10 borrowed E/M codes.

PLEASE NOTE: Because the CMS bases the current year’s OPPS allowable payment rates on the PBDs’ claim charges reported 2 years prior, PBDs are incentivized to update their clinic visit charges every year. Otherwise, the OPPS payment rates will not continue to reflect increases or decreases in the PBDs’ costs for various levels of clinic visits.  

Because physicians/QHPs followed either the 1995 or 1997 E/M guidelines published by the American Medical Association prior to January 1, 2021, and because each PBD wrote its own guidelines for the borrowed E/M codes, the CMS informed PBDs that the CMS did not expect the PBDs’ clinic visit levels and charges to mirror the E/M code levels and charges of the physicians/QHPs who provided services in the PBDs.

Then, in Change Request 8572, the CMS announced that, effective January 1, 2014, the CMS 1) recognizes HCPCS code G0463 for payment under the OPPS for outpatient hospital clinic visits, and 2) no longer recognizes 99201–99215 for payment under the OPPS.1 Per the normal CMS protocol, they used all the clinics’ visit charges, for 99201–99215 reported on the claims from the prior 2 years, to calculate the 2014 OPPS payment for G0463.

Please note a few very important points about Change Request 8572:

•    The major reason given for this change was to reduce the administrative burden of the PBDs to determine 1) whether a patient was new or established, and 2) the resources used during the visit.

•    It did not say the PBD should report one charge for G0463 when different levels of clinic visits were provided. In fact, if PBDs began reporting only one charge for G0463, their future OPPS rates for G0463 would most likely decrease.

•    It did not necessarily apply to private payers. Therefore, the PBDs typically continue to use their clinic visit mapping tools to determine the appropriate clinic visit level and charge. They enter the appropriate 99201–99215 code into their charging system. Then, for Medicare claims, the coders/billers convert the borrowed E/M code to G0463, but report the charge attached to the borrowed E/M code. This informs the CMS about the PBDs’ various costs for the clinic visits even though they report the visit with one code: G0463.

3.    The procedure code 97602 pertains to debridement, not clinic visits:
Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

For a PBD to report this code, the physician/QHP must write a debridement order and the PBD wound care nurse must perform and document a non-selective debridement. This code is not a “dressing change” code. In fact, a “dressing change” code does not exist for the PBD because Medicare does not consider dressing changes a medically necessary reason for a PBD visit. Therefore, 97602 should not be reported rather than G0463.

Summary    

Now that you know the facts, you should understand that:

•    PBDs should not report the same clinic visit level as the level of E/M services reported by the physician/QHP.

•    PBDs are not procedure based departments and should report clinic visits and appropriate charges when a procedure is not performed.

•    When the physician/QHP writes an order for the PBD wound care nurse to assess the wound, the PBD should report a clinic visit with the appropriate charge.

•    When the physician/QHP writes an order for the wound care nurse to assess the wound and debride it with either wet-to-moist dressings, an enzyme, abrasion, or larval therapy, the PBD should report 97602.  

•    The new E/M guidelines that became effective on January 1, 2021 are only applicable to physicians/QHPs when they perform E/M services in their offices or in an outpatient or other ambulatory facility. Therefore, PBDs should not base their clinic visit levels on the time spent by the wound care nurses.  

•    If PBDs want their OPPS allowable rates for G0463 to increase or decrease based on the PBDs actual costs, the PBDs should charge different rates for G0463 based on the level of service performed during their clinic visits.

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

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Reference
1. Centers for Medicare and Medicaid Services. Change Request 8572. Published Dec. 27, 2013. Last accessed Aug. 21, 2021.