In this issue:

• Highlights of the Proposed 2007 OPPS Rules Affecting Emergency Departments and Overview of Revised Draft AHA/AHIMA Guidelines
• ICD-9-CM Revisions Effective October 1, 2006

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Highlights of the Proposed 2007 OPPS Rules Affecting Emergency Departments and Overview of Revised Draft AHA/AHIMA Guidelines

As many of you are aware, CMS published the 2007 Proposed Outpatient Prospective Payment System (OPPS) rules in the August 8, 2006 Federal Register. The full text can be found in the first document, CMS-1506-P by clicking here. Providers are invited to comment on the proposed rule through October 10, 2006. CMS will consider and use comments to create the 2007 OPPS final rule expected to be published in the Federal Register in early November. Following are relevant points in the proposed rule that affect ED facility coding:

Visits

There are still no ED or clinic coding guidelines proposed for 2007 and CMS states that hospitals should continue to use their current systems that meet the general CMS guidelines outlined in year 2000 and subsequent year’s OPPS final rules. (See below for revised AHA/AHIMA guidelines discussion.)

CMS is proposing two types of EDs:

1. Type A EDs are open 24/7 and meet one of the following requirements: the ED is licensed by the state as an emergency room or emergency department or it is held out to the public as a facility that provides emergency care on an urgent basis and does not require previously scheduled appointments.
2. Type B EDs are considered “dedicated” EDs but they are not open 24/7. To be considered a Type B ED the facility must meet at least one of the following requirements: the ED is licensed by the state as an emergency room or emergency department or it is held out to the public as a facility that provides emergency care on an urgent basis and does not require previously scheduled appointments or if during the prior year, in a representative sample of patients, the ED provided at least one-third of its outpatient visits for treatment of emergency medical conditions without requiring a previously scheduled appointment.

CMS is proposing five new HCPCS G codes to code each of these ED types and clinic levels and two new HCPCS codes for critical care.

CMS proposed a total of 17 new HCPCS codes for outpatient coding in 2007.

The five new clinic HCPCS level codes make no distinction between new and established patients.

There would be five APCs for each of the two types of EDs and five for clinic visits replacing the current three APCs for each. Clinic visits and type B ED visits would group to the same APC and payment rate.

Critical care would be coded for a service meeting the critical care CPT descriptor including documentation of a minimum duration of 30 minutes. If critical care is less than 30 minutes, ED visit levels would be charged. Both 99291 and 99292 have HCPCS and APCs but 99292 is packaged and would not be separately paid.

Drug Administration

CMS proposes to continue using a combination of C codes and CPT codes, same as in 2006.Currently CMS pays for the initial hour of infusion and packages subsequent hours; the proposed rule contains language that subsequent hours would be paid separately in 2007.

Observation

Under the proposal Observation would continue to be coded using HCPCS G codes, same as in 2006.

CMS would continue to pay for Observation for only the following three conditions: CHF, chest pain and asthma.

The direct admit to Observation HCPCS code, G0379, would group to the same new APC as a low level clinic visit.

Proposed Financial Changes

The 2006 conversion factor of $59.511 will increase to $61.511 for 2007 in the proposal.

The maximum patient co-pay will remain at 40% of the APC payment rate; the range of co-pays is 20-40% of the APC payment.

Outlier status would be invoked when ED costs for a service exceed the APC payment rate by 1.75 and at least $1825. Current thresholds are 1.75 and $1250.  The outlier payment would be 50% of the difference between the APC payment rate and the facility’s actual costs.  This outlier payment would be paid in addition to the APC payment rate for the service or procedure provided.

Payment rate increases are proposed for ED levels 2, 3 and 5.  Levels 1 and 4 would have separate APCs, unlike in 2006 and years prior, and would have a lower payment rate than in 2006.  Observation and Critical Care payments are proposed to increase.

Draft AHA/AHIMA ED and Clinic Coding Guidelines

In addition to the proposed 2007 OPPS changes, CMS also released a revised version of the 2003 AHA/AHIMA guidelines for coding ED and Clinic services. CMS is considering these guidelines for future implementation but outlined eight significant concerns with them and invited provider comments. CMS will review comments throughout 2007 and stated that it will give providers 6-12 months prior notice before implementing any new outpatient coding guidelines. CMS does not expect to implement national guidelines prior to calendar year 2008.

 

In the proposed 2007 OPPS rule CMS described its concerns and other issues related to the AHA/AHIMA guidelines.  Following are highlights of the discussion:

Facilities will continue to use their own charging systems in 2007 but CMS has published revised AHA/AHIMA guidelines (found in the link above and clicking on the document: Draft AHA/AHIMA Guidelines with Suggested CMS Revisions toward the end of the list of documents).  CMS indicated the AHA/AHIMA guidelines are the “most appropriate and well developed guidelines for the OPPS” but listed eight significant issues:

1. contains three versus five levels of codes
2. a lack of clarity for some interventions
3. treatment of separately payable services
4. some interventions appear to be over-valued
5. concerns with specialty clinics
6. the Americans with Disabilities Act
7. differentiation between new and established patients and between standard visits and consultations
8. distinction between Type A and Type B Emergency Departments

CMS does not expect to implement coding guidelines for EDs or clinics before 2008 and will give providers 6-12 months notice before implementation.

CMS is reconsidering the rule on the exclusion of separately billable procedures

The revised model adds levels 2 and 4 which are reached when 3 or more asterisked interventions from the levels below (1 and 3) are performed or one contributory factor is performed in addition to a level 1 or 3 intervention.

The AHA/AHIMA guidelines are formatted in a grid and calculate ED visit levels in the following manner—refer to Draft document in link above:

1. The coder or nurse reviews the record for documentation of any facility intervention completed by nursing or ancillary staff.
2. To qualify for levels 1, 3, and 5 at least one listed intervention must be performed and documented.  Clinical examples are provided to assist the coder or nurse to select the appropriate level.
3. Some interventions in levels 1 and 3 have asterisks in front of them; if three interventions with asterisks are documented the visit level can increase by one level to level 2 or 4 respectively.
4. There are eight categories of “contributory factors” listed in the guidelines.  If one or more of these “contributory” interventions are performed and documented they will increase level 1 and 3 interventions one level to level 2 and 4 respectively.  You can not use a contributory factor to increase a level 2 or 4 to level 3 or 5.
5. If no level 1, 3 or 5 interventions are found in the record but a contributory factor is found the record may be coded a level 1.
6. Critical care may be coded if at least 30 minutes of critical care are documented and at least one listed critical care intervention is performed and documented.
7. Clinic visit levels are calculated in the same manner as described above.

CMS invited provider comments and indicated that they may be reviewing versions of other guidelines and will share these with providers in 2007.

ICD-9-CM Revisions Effective October 1, 2006 (for ED Coding)

It’s that time of year again to become familiar with ICD-9-CDM deletions, additions and revisions. The codes go into effect October 1, 2006 and there is no grace period. If valid diagnoses codes are not used for dates of service on or after October 1, 2006, claims will be denied.

There are 287 ICD-9-CM code changes. ICD-9-CM codes that may be encountered while coding ED encounters are in three separate groups detailing deletions (invalid codes as of October 1, 2006), additions and revisions. Not all 287 code changes are presented in the links below:

Invalid ICD-9 Diagnosis Codes (deleted codes), click here.

New ICD-9 Diagnosis Codes (additions), click here.

Revised ICD-9 Diagnosis Codes, click here.