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Find yourself in the middle of multiple doctors?

Hereís how to code for more than one provider and level of care

Keywords: ICD-9 codes - billing for observation, multiple physicians, incomplete procedures, and discharge management

by Tamra McLain, CPC, CPC-H, CMC

Published in the February 2009 issue of Today's Hospitalist

GIVEN THE DIFFERENT LEVELS of care that patients receive in the hospitalóthink observation vs. ED care or admissionóand the number of doctors who treat inpatients, itís no wonder that hospitalists get confused about how to bill and code their services.

Here are answers to some recent questions from readers of Todayís Hospitalist. (Keep those questions coming!)

Repeat H&P?
Q: I have heard that when a patient is first admitted to observation and then changed to inpatient status, we need to do a repeat history and physical using inpatient codes. If thatís true, how
Is it OK to refer to previous documentation to meet some history requirements?

much documentation is required? May I, for instance, say, ďNo change in family history from that documented in H&P of given date,Ē or do I need to re-dictate the whole thing?

And should the repeat H&P be at a lower level (such as 99221, for instance, instead of a 99223) because most of the work was done just 24 hours before?

A: You do need to do a new H&P to meet the code criteria. As for referring to previous documentation to meet some history requirements, there are different schools of thought. Some experts claim that if the existing documentation is your own, you know your documentation style and can feel comfortable that you met the required elements. If youíre relying on other physiciansí documentation, on the other hand, you canít be sure that they didnít overlook an important coding rule for a certain level of service.

I recommend erring on the side of caution and presenting new information with each H&P or consult that you code. The risk of not getting paid for your full service isnít worth the time you save by taking a shortcut.

And if you are performing all the work associated with a higher level admission, there is no reason to code and bill for a lower level H&P. Bill the appropriate level based on your amount of history, exam and medical decision-making.

More on observation
Q: I have questions about billing for both ED and hospitalist services for patients in observation.

First, if we have a hospitalist who is part of an ED group and who cares for a patient in observation, how do we bill for the hospitalistís servicesóand can we still bill for the ED visit? If, however, an ED doctor and a hospitalist work for (and bill from) different entities, can both the ED visit and the hospitalistís observation services be billed?

Also, Iíve heard that the guidelines for billing observation codes are changing in 2009 so we can no longer bill for both ED and observation visits, regardless of who renders the care or admits the patient to observation. Is this true?

A: For the first scenario, you can appropriately bill either 99218-99220 (admit to observation) or 99234-99236 (admit/discharge same calendar day) for the hospitalist, depending on whether the patient was admitted and discharged on the same day or on different calendar days. Itís just all one service under observation, so do not code for the ED visit (99281-99285) in this situation.

In the second scenario, you can bill for both the ED visit and the hospitalist admission to observation because the two physicians are in separate groups. As for changes to observation billing this year, I havenít heard of any and canít find anything to support the changes youíve outlined.

Two-physician billing
Q: If hospitalist A admits a patient at 2 a.m. and hospitalist B discharges that patient at 6 p.m., how should we code that? And how should we bill that same scenario if the admitting note is performed by the primary MD but the discharge is performed by hospitalist A?

A: In the first situation, bill the same-day admit/discharge codes (99234-99236) for hospitalist A.

Technically, you should do the same in the second scenario. But if the primary care physician and the hospitalist work for two different groups, what will probably be billed is a 99221-99223 (initial hospital admit) for the primary physician and a discharge code (99238-99239) for the hospitalist.

While this is not entirely kosher for patients admitted and discharged on the same day, it does allow both groups to be reimbursed for their respective services, instead of ďpayingĒ the primary care group for the hospitalistís service as well.

Invasive procedures
Q: I frequently perform invasive bedside procedures such as CNS chemotherapy with spinal puncture; ultrasound guide and vascular access; puncture/drain peritoneal cavity; and drain/inject major joint or bursa.

When I initiate a procedure but donít successfully complete it, may I still generate a bill? And do you know of any resource that I can use for procedure descriptors? For example, what documentation do I need to bill a 76937 (ultrasound guide, vascular access)?

A: Yes, you can bill for a procedure not successfully concluded. Consider using the modifier -52 to indicate reduced services if the procedure was not entirely completed because of anatomical reasons, for instance, or mechanical ones. If the procedure was stopped due to the patientís well-being, use modifier -53 for discontinued services.

As for documenting 76937, document that you performed the ultrasound to complete the main procedure and include the procedure note as well.

I think the Ingenix ďCodersí Desk ReferenceĒ is a great tool because it uses laymenís terms to spell out what you need to meet the criteria for a particular CPT code. This might be a good resource for physicians to figure out how to document the main points of a procedure.

Discharge management
Q: My question is about discharge management and codes 99238-99239. What documentation do I need to use either of these codes?

A: Time is the key factor in selecting discharge codes. Unlike other evaluation and management services, the criteria for discharge codes do not pertain to different levels of history, exam and medical decision-making. If you spend more than 30 minutes on discharge, use 99239; anything less defaults to 99238.

According to CPT guidelines, discharge management includes the following, when appropriate: final patient examination; discussion of the hospital stay; instructions on continuing care to all relevant caregivers; and preparation of discharge record, prescriptions and referral forms.

Tamra McLain is coding regional manager with MedData Inc. E-mail her your documentation and coding questions at Weíll answer your questions in a future issue of Todayís Hospitalist.

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