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OPPS Proposed Rule Significantly Affects Coding

Michelle Leppert, for HealthLeaders Media, July 10, 2013

"This proposal, if finalized, could result in significant financial impact for hospitals depending on the distribution of low and high visits they have," says Shah. "Moreover, this proposal may be coming from CMS' desire to create payment parity between the hospital-based clinic setting and physician offices. The agency has historically indicated that the existing E/M visit reporting and payment were fine as is under the OPPS despite provider group and industry organizations asking CMS to provide national guidelines and make changes to the current E/M structure for years."

This proposal, if finalized, would pay a single APC for clinic visits regardless of what type of clinic the patient visits and regardless of the facility resources expended. "The one good thing about CMS' proposal is that the need to differentiate between new vs. established patients would be eliminated and so may the need for facility-specific guidelines," says Shah.

This proposal seems to be a big step to try and standardize the use of a set of codes that can vary from facility to facility based on internally developed facility-specific guidelines, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM at HCPro, Inc., in Danvers, Mass.

Technical E/M services have always been an area of concern. It is difficult to measure and consistently report facility E/M codes to fairly account for resources used without encouraging overutilization, she says.

"This standardization would take out the guess work of did we over-report or under-report the technical E/M service level?" McCall adds "But, as with any change, if it affects the overall payment the facility receives it may not be received with thunderous applause especially if that means less revenue for some cases. Hopefully, the calculation of the one payment per type of HCPCS service code billed is one that is going to be somewhat budget neutral and not ones where the reimbursement overall suffers."

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