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2009 Facility E/M Levels under OPPS / TriAssess Premier Software Compliance
The following question and answer appeared in APCs Weekly Monitor (December 2008).
Q. Can you update me on any changes regarding the E/M CPT codes that hospitals must use for 2009 OPPS?
A. For 2009, hospitals must continue to use their internally developed guidelines for ED and clinic E/M visits, and adhere to the 11 principles developed in 2008 by CMS. Review the 11 principles with your facility E/M criteria team to maintain the circle of compliance for this reporting requirement.
The 11 principles follow. The coding guidelines should:
1. Follow the intent of the CPT code descriptor; the guidelines reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
2. Relate to hospital facility resources, not to physician resources.
3. Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
4. Meet HIPAA requirements.
5. Only require documentation that is clinically necessary for patient care.
6. Not facilitate upcoding or gaming.
7. Be written or recorded, well-documented, and provide the basis for selection of a specific code.
8. Be applied consistently to all patients in the clinic or ED to which they apply.
9. Not change frequently.
10. Be readily available for FI (or, if applicable, MAC) review.
11. Result in coding decisions that other hospital staff or outside sources can verify.
CMS has changed the definition for distinguishing between new and established facility E/M levels for 2009 from whether the patient has had a medical record number created within the past three years to whether the patient was registered as an inpatient or outpatient within the past three years.
Wound Care Strategies and APCs Weekly Monitor recommends a dedicated plan for performing detailed audits in all areas that report E/M levels. This will help ensure consistency, accuracy, and incorporation of the clinic definition that distinguished between new and established E/M levels. Monitoring modifier -25 (significant, separately identifiable E/M service by same physician on the same day of the procedure or other service), will help identify potential recovery audit contractor vulnerabilities. This is especially true for clinics which perform scheduled procedures along with medical visits on the same day.
To that end, please find two articles that may assist you in developing your wound care audit plan
Developing a Wound Care Compliance Program (Part 1)
Developing a Wound Care Compliance Program (Part 2)
CMS' HCPCS Coding Decision for Skin Substitute Products
November 2008
The Centers for Medicare and Medicaid Services announced modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. All changes are effective January 1, 2009, unless otherwise indicated in the effective date column.
Notice regarding CMS' HCPCS Coding Decision for Skin Substitute Products:
The 2009 HCPCS Annual Update includes a new code series, Q4100 – Q4115, effective January 1, 2009, to identify skin substitute products. Codes J7340, J7341, J7342, J7343, J7344, J7346, J7347, J7348, J7349 and C9357 are discontinued effective 12/31/2008.
CMS Standing Orders Clarification Letter/TriAssess Premier Software and The Admission Assessment Manager
On October 24, CMS issued a memo clarifying the use of standing orders in hospitals and the circumstances under which signatures are required on pre-printed order sets. I thought this would be interesting for you to review and share with your team, if you have not already see this clarification memo.
TriAssess® Premier Software (TPS) and The Admission Assessment Manager™ ( TAAM) are compliant with the important requirements set forth by CMS:
- Provides evidence based protocols.
- Allows pre-defines order sets to be integrated into the software solutions.
- Captures date, time, and signature of the orders.
- Converts a patient’s weight from pounds to kilograms when prescribing medication.
- Promotes continuity of care documentation for all practitioners within the inaptient and outpatient departments.
- Authenticates the clinician and physician signatures.
- Prevents alterations of record entries.
- Permits surveyors to review sampled medical records while on-site in the hospital.
- Provides security features that maintain the integrity of the records.
In order for your facility to be clinically compliant and operationally efficient, your facility must have all processes in place. TPS and TAAM provide you with the platform to make you and your team members successful.
To view more information,click here to view the PDF.
TriAssess Premier Software supports CMS E/M Services
"If it is not documented, it is not done". A phrase we have all heard, and continue to hear in this day and age. Computer-based documentation solutions, such as TriAssess Premier Software (TPS), have emerged to capture your complete medical record for skin and wound care and HBOT. TPS has the ability to track your clinical activities and outcomes, tie time as a function of the program to determine your cost of care, integrate pathways and algorithms to assist you with clinical and regulatory compliance, and benchmark your work performed.
Documentation is a process. Our clients know that process is the key to success! Process is the thread that pulls work, documentation, and payment together. Regulations and guidelines formulated by third-party payers often dictate the actions of these threads (see attached). It is critical that all of your personnel associated with the performance of wound/HBOT care become knowledgeable of stated guidelines and regulations.
To that end, I would like to share the latest CMS Evaluation and Management Services Guide (July 2008) with you. I share this with you for a number of reasons:
1. It is important that your clinical/medical staff remain current with CMS documents;
2. It is important that your clinical/medical staff understand the importance of capturing their work and how that work translates to payment; and
3. It is important that your clinical/medical staff understand that TriAssess Premier Software captures all of the clinical elements necessary to support the evaluation and management services.
In order for proper documentation and payment to occur, your facility must practice by a process. TPS provides you with the framework of documentation to make you and your team members successful.
To view CMS' Evaluation and Management Services Guide,click here to view the PDF.
CMS to expand quality initiatives
On April 14, CMS issued a new proposal to expand two key initiatives that link Medicare reimbursement for health care services to quality of care. For the Hospital-Acquired Conditions (HACs), CMS is looking to expand the list of conditions by nine to a total of 17 conditions. This means that, if approved, starting October 1, 2008, Medicare will no longer pay a hospital at a higher rate for these conditions.
The second initiative involves the hospital quality measure reporting program. CMS is proposing to expand the list of 43 quality measures to 73 quality measures starting in 2009.
For more information,
Click here to view the press release, then click on the link for "CMS PROPOSES TO EXPAND QUALITY PROGRAM FOR HOSPITAL INPATIENT SERVICES IN FY 2009".
Tricenturion Transition
Important information regarding the transition of medical review not in support of benefit integrity from TRICENTURION, the region AB Program Safeguard Contractor, to the Medicare Affiliated Contractors for jurisdiction A and B has been posted via the Tricenturion website.
For more information,
click here to view this information in its entirety..
CMS Releases January 2008 update of the Hospital Outpatient Prospective Payment System (OPPS)
CMS has released the January 2008 update of the Hospital Outpatient Prospective Payment System (OPPS). Transmittal 1417 is quite lengthy and includes important changes regarding billing of wound care services. The information is related to CPT codes 97597, 97598, 97602, 97605 and 97606.
For more information,
click here to view this information in its entirety..
Tricenturion Transition
Important information regarding the transition of medical review not in support of benefit integrity from TRICENTURION, the region AB Program Safeguard Contractor, to the Medicare Affiliated Contractors for jurisdiction A and B has been posted via the Tricenturion website.
For more information,
click here to view this information in its entirety..
Recent Results Released regarding Pre-payment review for Foam Dressings
TriCenturion, the Jurisdiction A/B DME PSC, has completed the 1st quarter of a widespread,
pre-payment review of Foam Dressings, HCPCS A6209-A6214, billed with the A1 modifier.
The data analysis identified a significant number of beneficiaries who received excessive dressings as
compared to the LCD allowable number of services (NOS). 98% of the claims were denied as Medicare policy
criteria were not met.
To read this article in it's entirety use the following website link
For more information,
read the article.
Final OPPS Rule released by CMS
On November 1, 2007 The Centers for Medicare & Medicaid Services (CMS)issued the
final rule updating the hospital Outpatient Prospective Payment System (OPPS),
effective for services furnished during calendar year (CY) 2008, which encourages
higher quality and accessible health care through new payment policies and the
reporting of quality measures.
This final rule affects outpatient services furnished by general acute care
hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities,
and long-term acute care hospitals.
For more information,
read the article.
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