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How should you bill an AMA discharge?

Plus, coding questions on comanagement, consults and transfers

Keywords: ICD-9 Comanagement billing, coding for discharge against medical advice, and postoperative care modifiers

by Tamra McLain, CPC, CPC-H, CMC

Published in June 2010 issue of Today's Hospitalist

ITíS AMAZING THE RANGE OF SERVICES that hospitalists provide, which gives rise to all kinds of questions about how to bill for those services and get paid. From coding for discharge against medical advice and transfers to comanagement billing, here are some of the questions readers have asked, and my suggestions.

Comanagement, or not
Q: An orthopedic surgeon performs various surgeries, mostly knee replacements, then asks our group to provide all postop care for patients in the hospital. How should we bill for these services?

A: Use the subsequent hospital visit
Use modifiers to indicate preoperative or postoperative care.

codes (99231- 99233). The easiest way to justify the medical necessity of these visits is to include any other conditions and/or exacerbations you are monitoring within the diagnosis codes, as well as V codes for any type of postoperative condition. (The V54.0ĖV54.9 series is for orthopedic aftercare.)

However, you may find that some patients donít have other conditions to monitor or evaluate. With these patients, Iíd recommend billing subsequent visit codes and using a modifier -55, indicating postoperative management only.

Q: When a patient with a hip fracture presents to the ED, the orthopedist is called but may not be able to see the patient for a couple of hours. The orthopedist asks the hospitalist to perform the admission and history and physical, then comes to the ED later to do the hip repair. Because the orthopedist bills a global surgical fee such as a 27244 (hip repair), does this prohibit the hospitalist from billing an initial visit (99221-99223)?

A: The hospitalist can bill the initial hospital visit (99221-99223) with a modifier -56, which indicates preoperative care only.

Discharge AMA or patient death
Q: How should we bill for either a death or a discharge against medical advice on the same calendar day as a subsequent visit performed by another hospitalist within the same group?

A: Unfortunately, payers donít provide any way to bill for both services on the same date. Both a subsequent visit and a discharge AMA (or a death) would have to be combined and billed under one CPT code.

For an AMA discharge, some practices use the higher level discharge code (99239) as long as doctors document time spent advising a patient not to leave. (Remember, discharge codes are time based.) Other groups combine the efforts of both the subsequent visit and the AMA discharge and code a higher level of subsequent visit (99231-99233). Either is acceptable. I recommend that your group pick the policy it is more comfortable with and document it in your compliance plan.

As for when a patient dies, I have heard it argued that because discharge services must be face-to-face, using a discharge code wouldnít be appropriate. Instead, assess the time spent on closure with the family and bill the subsequent visit code (99231-99233).

Observation status
Q: How should we bill an initial observation code when a patient is admitted to observation on one date but not seen or evaluated by a physician until the next calendar day? The patient is subsequently discharged the same day as the initial evaluation.

A: You canít bill anything for day 1 because the physicianís evaluation wasnít done until the next day when the patient was seen, treated and discharged.

Use the same-day admit and discharge (99234- 99236) codes based on your level of history, exam and medical decision-making. Remember, the Centers for Medicare and Medicaid Services (CMS) expects patients to be in observation for at least eight hours if same-day admit and discharge codes are used. For Medicare patients not kept eight hours or more, bill using observation admission codes (99218-99220).

Patient transfers
Q: Sometimes, one of our hospitalists sees a patient in the ED and determines that the patient should be admitted but transferred to another facility within our system. How do we bill that encounter? Does the physician who sees the patient in the ED bill an admission, while the accepting physician bills a subsequent visit?

A: The hospitalist who sees the patient in the ED should bill an outpatient consultation code (99241- 99245), as long as the patient isnít covered by Medicare and the ED physician makes the consult request.

For Medicare patients, the first hospitalist should bill an initial visit code (99221-99223) and the physician who receives the patient on the same date should bill for a subsequent visit (99231-99233). Payers may ask to see documentation for both encounters to determine why the physicians should be paid separately.

Q: One of our hospitalists was the admitting physician for a Medicare patient in a rehab facility who had acute and chronic respiratory failure. The hospitalist asked a pulmonary subspecialist in a separate group for a consult.

Both doctors billed their services on the same date with the same diagnosis code, 518.84 (acute and chronic respiratory failure), and the pulmonologist billed an initial visit (99223). But the hospitalistís bill was denied due to duplicate billing. How should we submit this claim to get it paid?

A: Actually, the pulmonologist has it right: He or she should bill the acute and chronic respiratory failure code (518.84) and the appropriate level of initial visit (99221-99223).

However, the hospitalist will likely have a list of comorbidities or conditions being seen, along with the respiratory failure. The hospitalist should include those in the list of diagnosis codes to describe the medical necessity involved with the appropriate level of his or her initial visit code (99221-99223).

Also, for Medicare patients, the hospitalist should attach modifier ď-AlĒ to the initial visit code to indicate that he or she is the admitting physician. If the claim is still being denied, you may need to make an appeal and justify the service.

Tamra McLain is client services manager with MedData Inc. E-mail her your documentation and coding questions at tamram@meddata. com. Weíll answer your questions in a future issue of Todayís Hospitalist.

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