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Who bills for what in comanagement?
Getting past the confusion over how to split physician billing

Keywords: ICD-9 coding - explanations for split physician billing, comanagement, and consults


by Tamra McLain, CPC, CPC-H, CMC



Published in the April 2009 issue of Today's Hospitalist

WHETHER IT’S SURGICAL PATIENTS or individuals being transferred from the ICU to the floor, hospitalists end up sharing care with so many physicians that they often can’t figure out how to split up the billing. Here are questions from readers trying to determine how to bill within those complicated arrangements.

Comanagement and transfer billing
Q: We comanage orthopedic patients with hip/femur/ knee fractures. The ortho service does the history and physical and the discharge summary. We, however, charge 99221-99223 for an initial visit and then 99231-99233 for all subsequent ones, but we
When a surgeon transfers care, you don’t need to change the principal diagnosis codes.

do not bill for discharge. Is this the right way to go?

A: Because orthopedists are doing the history and physical, they should be billing the 99221-99223 (initial visit), not the hospitalist. Instead, stick to billing for your subsequent visits (99231–99233) based on each visit’s level of history, exam and medical decision-making. You’re correct that the orthopedist should be coding for the discharge service, not the hospitalist.

Q: In our hospital, the intensivists—who are a separate group—follow patients during their ICU stay and then transfer care to us on the floor. We bill 99231-99233 for subsequent visits and 99238-99239 for discharge services. Should we also bill 99221-99223 for an initial hospital visit when the patient is transferred?

A: No, you’re in the same position as the reader in the previous question. It’s incorrect to bill a new initial hospital visit for the same hospital stay. Capture your services with subsequent visit codes and then bill the discharge service.

Q: Surgeons frequently transfer their complicated patients to our hospitalist service to manage complications or treat medical conditions. We insist that they change the patient’s principal diagnosis on transfer of care. However, while the surgeons continue to be reimbursed, our bills often are denied. Should we use the modifier -55 (postoperative care only) for our services and should the surgeons add the modifier -54 (surgical component only) to theirs?

A: Not necessarily. If a surgeon seeks your opinion or advice for a complicated medical condition, you may want to bill a consultation code (99251-99255). Make sure you document the name of the referring physician and code the medical conditions that apply. In such a situation, neither of you would have to use modifiers.

If, however, the surgeon is stepping away and the hospitalist continues the postoperative management, you’re right. Surgeons should append their surgery charges with a -54 modifier, and all hospitalist postop services would need a -55 modifier. Finally, there’s no need to change the principal diagnosis. When the surgeon transfers care, your group should be able to use the same diagnosis codes.

Critical care
Q: How do I bill for two pediatric intensivists performing critical care services for the same patient on the same day at different times? My understanding is that the first physician would bill 99291 (critical care services that take between 30 and 74 minutes) and, if applicable, 99292 (for every additional 30 minutes).

The second provider, however, could bill only 99292 for the time increments that he or she provided care. Is that correct?

A: Yes, that’s correct. According to CPT guidelines, critical care billing is based on time spent during one calendar day. The second physician should not go back and start charging a 99291 again. In the past, I have seen the Centers for Medicare and Medicaid Services reject claims for 99292 when billed solo by a second physician. However, filing a simple appeal with documentation justifying that physician’s services should get the claim reimbursed.

Billing for consults
Q: Please clear up a few questions on billing for hospitalist consults. How important is it to include the name of the referring physician in the consult content or note? Is there any difference between noting “Assessment and plan” vs. “Impression and recommendation”? And is any closing statement required or preferred?

A: It is absolutely essential to list the referring physician in your consultation note. You can bill consultation codes only if you’re rendering an opinion or advice for a colleague’s patient. To get paid for the service, coders need to attach the name of the physician initiating the request. I don’t see any difference between “Assessment and plan” and “Impression and recommendation”; I’d say they are synonymous. Finally, I think it’s good to end with the patient’s final diagnoses and final disposition (discharged, admitted or transferred).

Same-day admit/discharge
Q: Say a patient is admitted to either inpatient or observation status on one day and is seen that day by a resident. But the attending isn’t able to work the patient up until the next day, which is the day that the patient is discharged. Should we bill 99234 (admit/discharge same day)? If not, what code should we use?

A: It would be appropriate to bill 99234-99236 (admit/ discharge on same calendar day). You cannot bill for a date of service on which the attending was not involved in the patient’s care. If the payer denies this claim because your date of admission conflicts with information provided by the hospital, submit documentation showing that no one provided service on that date as part of your appeal.

Post-code billing?
Q: How do I bill for a second visit in one day by a different physician within the same group? We have been billing for critical care services when responding to codes, but most of our “second visits” are for non-code situations. If one criterion for billing another visit on the same day is a new problem, does the new problem have to be a new condition or can it be an exacerbation of a previously stable problem?

A: Government payers are more stringent about the rule against paying for two visits on the same day by different doctors within the same group. In those cases, a new condition would be most helpful; an exacerbation of a stable condition would count as well.

Commercial payers might be more flexible paying for two visits by different physicians for the same problem on the same day. If they need a nudge to reimburse both visits, be sure to submit documentation.

Tamra McLain is client service manager with Med- Data Inc. E-mail her your documentation and coding questions at tamram@meddata.com. We’ll answer your questions in a future issue of Today’s Hospitalist.
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