Published in the May 2015 issue of Today’s Hospitalist
HOW SHOULD YOU BILL when two physicians in one group both see a patient on the same day or you have to factor in services that take place on a new date? Here are some questions from readers on the timing of admissions, subsequent visits and discharges.
Say I get a call from the ED at 11:45 p.m. and I place an admission order at 11:55, but I don’t see the patient until 12:20 a.m. Should I bill that 12:20 visit as subsequent care (99231-99233)?
You cannot bill a subsequent visit until you first have an initial face-to-face encounter with the patient. If the only service you provided before midnight was fielding the phone call from the ED and writing an admission order, then the face-to-face visit at 12:20 would be considered the initial visit. You, of course, wouldn’t bill anything for the ED call and admission order the day before.
If you had seen the patient at 11:55 p.m., however, and your documentation then supported initial hospital care (99221-99223), the bulk of that visit would have taken place after midnight. So chances are, you would have billed that initial visit using the next day as the date of service.
Keep in mind that hospital visits (both initial and subsequent) are paid on a “per-diem” basis. Payment is made only once for related care rendered by a provider or group on the same date of service.
Here’s the situation I have a question about: Dr. A sees a patient after midnight and bills a 99223 (a level 3 initial visit). Later that same day, Dr. B sees the patient for 30 minutes. Can Dr. B bill a 99356 (the first hour of prolonged inpatient services)?
I can’t tell from these details if there was a medically necessary indication “a significant change in the patient’s clinical condition or the development of a new problem “for Dr. B to see the patient later that same day. If Dr. B visited only because the patient’s name was on his or her rounding list or to “check in” to see how the patient was doing, the visit may not be separately billable.
A 99223 (initial care) requires both a comprehensive history and exam, and highly complex medical decision-making. Dr. B’s visit shouldn’t be billed unless the patient’s condition required additional clinical evaluation and management. (I’m assuming both physicians are in the same group and that both are hospitalists. Two doctors could bill for services to one patient on the same day if they were not in the same group or specialty and if they were each managing a different clinical problem.)
If the second visit was medically necessary and if both doctors are in the same group and specialty, you may consider billing prolonged services for the second visit. But you may bill those codes only if the total duration of face-to-face service by the physician or qualified NP equals or exceeds the threshold time for the E/M service provided. For example: The typical time associated with initial care (99223) is 70 minutes. You would not be able to bill prolonged care unless the total direct face-to-face time for the second visit exceeds that threshold by 30 minutes or more.
Also keep this in mind: When reporting prolonged care (99356-99357) for a Medicare beneficiary, the time reported must be face-to-face with the patient. This differs from the CPT definition, which holds that inpatient prolonged care codes can be reported based on unit or floor time.
Coding for discharges
How should we bill the following scenario: First, Dr. A does all the discharge work on Sunday and signs out the patient to Dr. B for Monday. (The discharge summary lists Monday as the discharge date.) The next day, Dr. B does a short follow-up note before the discharge.
Should Dr. A bill 99239 (discharge services of more than 30 minutes) or 99233 (a level 3 subsequent visit)? And should Dr. B bill 99231 (level 1 subsequent visit) or a 99238 or 99239 (discharge code)?
Another question: How should these doctors bill if the patient leaves Tuesday, not Monday? And what are the RVUs for each code? We are paid according to the RVUs we individually generate.
I’m going to assume the patient is a Medicare beneficiary. If Dr. A does all the required clinical work and documentation for the discharge (99238-99239) on Sunday and signs out the patient, then Dr. A should bill the discharge using Sunday’s date of service, even if the patient is not discharged until Monday.
As for Monday’s short follow-up note: If Dr. B did not have a medically necessary reason to perform key components of history, exam and medical decision-making or didn’t spend more than 50% of the visit face-to-face with the patient and/or family providing relevant educational information, then he or she shouldn’t bill anything on Monday. It should be a courtesy visit.
But if there was a medically necessary reason to perform those key components or if Dr. B spent more than 50% of the visit face-to-face on education, he or she should report and bill the appropriate subsequent visit level.
If the patient isn’t discharged until Tuesday, how to bill would depend on the reason why. If the patient couldn’t be discharged because his or her clinical condition changed, Dr. B may have to perform a new discharge service to address those medical issues.
Dr. A would have to change the discharge code billed to a subsequent visit, while Dr. B would bill the new discharge service. If that isn’t possible (if, say, Dr. A is in a different group and doesn’t agree to change the billed discharge code), Dr. B would submit a claim for an appropriate subsequent visit.
But if the patient’s discharge is delayed because of transportation issues or the family can’t equip the home soon enough, then Dr. B may not have a billable service on Monday. There must be a medically necessary reason for a visit, and a status check-in does not support medical necessity.
As for the number of RVUs for each code: Each group typically assigns its own values, so ask your practice administrator. For a general idea of how many RVUs are associated with different visit levels, go to the CMS Web page www.cms.gov and type “Physician Fee Schedule Look Up” in the search box. Just keep in mind that the RVU values listed in this tool are likely different from what your organization uses.