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OPPS Proposed Rule Significantly Affects Coding

Michelle Leppert, for HealthLeaders Media, July 10, 2013

Although the facility's costs for a clinic visit are likely to be relatively consistent for all patients, facility costs in the ED can vary considerably, Hoy says. That is especially true of nursing costs. Nurses can spend variable amounts of time with patients in the ED. If a patient comes in with road rash, the nurse could spend a lot of time cleaning the wounds, but that cost would not be reflected in the single ED visit code.

"I think this makes more sense in the clinic than it does in the ED," Hoy says. Shah is concerned that the proposal may be just as problematic for clinic visits because paying a single rate for all different clinic types ignores the different costs and services being rendered.

"There is a risk that certain providers may be systematically overpaid, while others may be underpaid depending on the types of clinics they have, the volume of patients, and the manner in which they deliver care," Shah says. "If the rate is inappropriately low, providers may be forced to reduce certain services or "rush" through others, such as education and teaching, care coordination, etc. CMS' payment policy shouldn't systematically penalize providers or patients, and must be reviewed carefully in the coming months."

CMS is also looking closely at provider-based clinics, which could be one reason for the E/M change, Hoy says. CMS will be collecting information about off-campus provider-based clinics.

CMS is looking for comments about the proposed E/M changes, so providers should review this proposal and submit their comments to CMS, Shah says.

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