AHIMA asks CMS to standardize E/M codes
AHIMA asks CMS to standardize E/M codes
G codes, E/M service coding changes needed
Many G codes are outdated and overlap other coding sets, and coding for evaluation and management (E/M) services needs to be standardized once and for all, according to the American Health Information Management Association (AHIMA) of Chicago.
AHIMA wrote the Centers for Medicare & Medicaid Services (CMS) of Baltimore in early October, asking CMS to make changes to these and several other troublesome coding areas. CMS had not replied to AHIMA’s suggestions as of the end of October 2002.
"Consistency in medical coding and the use of medical coding standards in the U.S. is a key issue for AHIMA," wrote Dan Rode, MBA, FHFMA, vice president of policy and government relations for AHIMA, and Sue Prophet-Bowman, RHIA, CCS, director of coding policy and compliance for AHIMA, in an Oct. 3 letter to Thomas A. Scully, administrator of CMS.
AHIMA points to changes to the Hospital Outpatient Prospective Payment Systems (PPS), published in the Federal Register on Aug. 9, and the calendar year 2003 rates and notes that there continue to be problems that need to be addressed.
"While many of the issues raised in the Aug. 9, 2002 proposed changes are important, two issues — the assignment of new codes and the coding for evaluation and management — are very troubling to AHIMA and shall be addressed first," the letter states.
Here are the issues and proposed changes:
• G codes.
There is a continued proliferation of G codes, despite the fact that they often overlap or duplicate other code sets and are inconsistent with the requirements and goals of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and lack basic data integrity, the AHIMA letter says.
"Under PPS there is a G code creep, where we get more and more G codes, escalating our concern about them," Prophet-Bowman says.
"G codes are of greater concern since HIPAA regulations related to electronic transactions and code sets talk about non-duplication," she adds.
While G codes may be necessary to identify new technology and medical advances for which Medicare and some other payers have agreed to reimburse (although these new procedures haven’t yet made it through the CPT coding process), the G codes often are not needed for the many other reasons they are used, Prophet-Bowman says.
G codes are a way to code temporarily until a CPT code is established, and AHIMA doesn’t have a problem with that use of G codes, she adds.
"But the other way they’re used is to capture specific information, and there’s no process in place to make sure they’re temporary," Prophet-Bowman says. "Some G codes have been around for years, and there’s no mechanism in place to say that by a certain time period there is a process to change it to a CPT code."
Plus, G codes usually are so specific to Medicare reimbursement that they are not used by other payers, which means facilities have to use duplicate codes for these services, which is both time-consuming and inefficient with regard to coding consistency and quality, Prophet-Bowman says.
Also, there are some cases where G codes are duplicated in CPT codes, which goes against the heart of HIPAA and coding data integrity standards, she says.
One example described in the AHIMA letter is of a new G code created for 2003 to describe a bone marrow aspiration and biopsy. This new code duplicates a CPT code that already exists for bone marrow aspiration and biopsy.
• Evaluation and management services coding.
"Our chief concern is the whole issue of national consistency in coding practices," Prophet-Bowman says.
"If each facility is developing its own reporting process for E/M services, then it will be difficult, if not impossible, to compare code utilization and E/M services from one facility to another because they won’t mean the same thing," Prophet-Bowman explains. "It makes data comparability across organizations pretty much nil."
For these reasons, AHIMA asks CMS to implement a standardized coding process for facility reporting of E/M services.
"We endorse the proposed establishment of unique codes to describe facility E/M services rather than continuing to use CPT E/M codes," the letter states. "We agree with CMS’ conclusion that the CPT E/M codes do not describe well the range and mix of services provided by facilities to clinic and emergency patients."
AHIMA recommends that CMS create a broadly representative panel to create these national standards.
While such standards need not be so rigid as to lack room for flexibility on the part of individual facilities, they could provide a standardized process that gives direction and that all hospitals could find worthwhile, Prophet-Bowman says.
• Inpatient-only list.
AHIMA also asks CMS to closely monitor the inpatient-only list and the ambulatory surgical center list of covered procedures to ensure consistency and to promote expeditious updates when medical practice changes.
Health care facilities are concerned that Medicare’s requirement that certain procedures only be reimbursed if they are provided in an inpatient setting unfairly regulates and restricts providers who may have found more efficient and better ways of providing these services, Prophet-Bowman says.
"A lot of our members don’t feel CMS should be in the business of regulating which setting patients should be treated in," she adds. "To regulate it in the guise of a reimbursement system is not where the issue should be addressed."
For instance, the setting in which many procedures are performed depends on regional practice. A Northeastern hospital may perform a certain procedure routinely in an outpatient setting, but a Southern hospital may still perform the same procedure on an inpatient basis. If Medicare is restricting reimbursement only to patients who have the procedure done on an inpatient basis, then this unfairly limits the options available to patients and physicians, Prophet-Bowman explains.
Medicare may argue that the agency doesn’t tell physicians where to perform procedures, but by restricting reimbursement the effect is essentially the same, Prophet-Bowman adds. "If you tell a patient, I would like to do this procedure on an outpatient basis, but Medicare will only pay for it as an inpatient service, so you’ll have to pay for it yourself,’ there are not a lot of people who’d say, OK, I’ll pay for it myself.’"
Many G codes are outdated and overlap other coding sets, and coding for evaluation and management (E/M) services needs to be standardized once and for all, according to the American Health Information Management Association (AHIMA) of Chicago.Subscribe Now for Access
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