Billing two visits a day for one patient? Not so fast

Billing two visits a day for one patient? Not so fast

Plus, NP employment and supervision

March 2017
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Published in the March 2017 issue of Today’s Hospitalist

IF THE PHYSICIANS in your group bill more than one hospital visit for the same patient in a single day, will they be paid? And if you work with nurse practitioners who are employed by a different entity than your own group, can you even fill (and bill for) a supervisory role?

If you’re not sure about the answer to these questions, you’re not alone. In this month’s column, we look at questions on these topics I’ve received from readers and my “bad news” answers.

Dual visits
I just started working as a hospitalist. The setup is such that one hospitalist sees patients in the morning while another sees the same patients in the evening. Can we bill for both visits?

If the physicians in your group routinely see patients twice a day, medical necessity could 
be called into question.

You don’t mention whether both hospitalists work for the same organization. Assuming they do, here’s my question: Why are you and your colleagues seeing patients twice a day?

Insurers pay for any medical service based on medical necessity. If the physicians in your program or group routinely see patients twice a day, medical necessity could be called into question.

Medicare views providers of the same specialty in the same group as one physician, and it pays for hospital visits on a “per-diem” basis. A second visit in one calendar day may be appropriate if a patient’s condition changes or if diagnostic test results require a change in management.

If you and your colleagues see the same patient on the same date of service for the same condition(s), you should select one level of service (99231–99233, subsequent hospital visit) based on the documentation of both doctors. If each hospitalist bills for a visit for the same patient on the same day, one of those claims will likely be denied.

NP supervision?
I work at a large academic center and am part of the physicians’ organization. The hospital employs nurse practitioners who are not part of that organization.

The NPs see our patients, and we work directly with them and oversee their care. But I’ve been told that because the NPs are not employed by the organization, we cannot “attest” to their work by writing a short note that agrees with their note, with comments on additional or differing findings with a plan. Do we have to write an entirely separate note?

I’m afraid you do. Physicians who do not employ and/or work for the same entity as the nurse practitioners with whom they practice cannot simply attest to the NPs’ work. As long as they are employed by separate entities, the NPs should submit their own claims for the patients they see, while hospitalists should separately submit theirs.

Physicians from one organization cannot provide supervision or oversight for NPs who work for a different one. You may be thinking that the teaching-physician rules set forth by Medicare for supervising residents apply to NPs, but they do not.

LTAC transfer
My question is about a patient sent to an acute care facility from an LTAC. While the patient was not admitted to the ER, he expired. Is the patient the financial responsibility of the LTAC or the ER?

I’m afraid I’m missing key details here, such as whether the LTAC and the acute care hospital are part of the same system, and where the patient expired.

But let me provide a few thoughts to consider. First, if the acute care facility “accepted” the transfer from the LTAC, this could influence where the financial responsibility lies.

Strict adherence to the Emergency Medical Treatment and Labor Act (EMTALA) would require the acute care facility to provide, at a minimum, a medical screening exam to patients who come to the ED, whether or not they are formally “admitted” to the ED. In the situation you describe, it appears that the patient may have expired in the ED. If that is the case, the financial liability may belong to the acute care facility.

Careful review of the documentation may also provide insight into what entity has financial responsibility for the patient. Pertinent details may include why the patient was transferred and when he expired, whether he was supposed to be seen in the ED or if he was a direct admission, and whether the receiving facility accepted the transfer.

Finally, Appendix V (Responsibilities of Medicare Participating Hospitals in Emergency Cases) of the State Operations Manual (CMS Internet-Only Manual 100-07) Interpretive Guidelines should provide some guidance.

Sue A. Lewis, RN, CPC, PCS, is a coding manager for a nonprofit health plan in the Midwest. Send any billing and coding questions you have to her at slewis56@q.com, and we may answer them in a future issue.

1 COMMENT

  1. I’m a nocturnist and fight with this issue a lot. If I see a patient after midnight to do an h and p and bill for it then my partner during the day shift cannot bIll for a subsequent visit unless “medical necessity” [is proven]. I feel this should change or maybe [there should be] an 8- or 12-hour rule. I hate doing this to my partners but oftentimes cannot help it. The other option is leaving it till the am. So seeing somebody at 23:00 and 08:00 is ok but 01:00 and 14:00 isn’t ? Makes no sense.

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