The Hospital Outpatient Prospective Payment System has been in place for nearly a decade, but I still get calls at least once per week about the correlation between the facility and physician level of service as reported by IntelliTrak.

For example, here is a recent comment, "We can’t have the physicians charging a 99214 and the clinic charging a 99212, this will surely throw red flags up!"

This concern about the disparity between the physician level of service and the facility level of service, while intuitive, is unwarranted.

CMS is clear in their expectations that in the facility setting, the physician is being paid for the cognitive effort of delivering care and the facility is being reimbursed for the work effort of delivering care.  In fact in the Federal Register, 4/7/2000, Medicare Prospective Payment System for Hospital Outpatient Departments, pp 18450 – 18451: CMS instructed facilities in the use of 31 CPT codes to reflect the work performed by hospital outpatient departments.  This is the original work where CMS required that HOPDs use codes 99201 – 5 and 99211 – 5.  CMS also points out that these codes (as described by the AMA) don’t adequately describe facility resources.

“We realize that while these HCPCS codes appropriately represent different levels of physician effort, they do not adequately describe non-physician resources. However, in the same way that each HCPCS code represents a different degree of physician effort, the same concept can be applied to each code in terms of the differences in resource utilization.”

Further, CMS went on to say that they didn’t expect to see correlation between the codes.

“Therefore, we would not expect to see a high degree of correlation between the code reported by the physician and that reported by the facility.”

I hope that this reference to CMS' stance is useful as you work through this issue.