Published in the December 2009 issue of Today’s Hospitalist
I DROPPED OUT OF AMBULATORY MEDICINE for a lot of reasons, including the need to double-book appointments and squeeze big problems into short visits. I felt guilty about keeping patients waiting and then rushing through their time with me in the office.
But one of the biggest factors that pushed me out of outpatient care was all the "free" care I had to deliver: digging through charts after hours and making phone calls to patients and other physicians. I know that a conscientious doctor will always do those things, but I started to resent the countless hours of unreimbursed services that cut into my family time.
So, hello hospital medicine! One of the many appealing things about practicing as a hospitalist was being able to bill based on time. When I started as a hospitalist about five years ago, I could bill insurers for many activities that constituted free care as an outpatient physician.
Inpatient physicians at that time could use prolonged service codes (99356 for the first hour of inpatient care; and 99357, for each additional 30 minutes) to bill for activities such as chart review, filling out forms and talking to other physicians about patient care. Outpatient doctors were reimbursed only when those activities were done face-to-face.
But being able to bill for non-face-to-face care was too much of a good thing, at least in the eyes of third-party payers. A rule change from the Centers for Medicare and Medicaid Services (CMS) last year has now put us in the same face-to-face camp as outpatient physicians when billing for prolonged services. As I result, I’ve learned to work smarter so I can still legitimately bill for all the services that I provide.
"Doughnut" and "black" holes
For a lot of physicians, billing prolonged service codes has always been confusing. That’s because we can’t start the clock on billing those services until we’ve passed the typical time period associated with the evaluation and management (E/M) code we’re adding the prolonged service code to.
And the CMS has always denied payment for the first 29 minutes of any prolonged service beyond that E/M service time threshold, regardless of how it was delivered (face-to-face or not). You lose roughly $2 per minute ” call it the "doughnut hole" for doctors “until you spend at least 30 minutes providing a prolonged service.
But consider how our reimbursement has been affected by the CMS rule change. Take an 80-year-old patient who’s been admitted for confusion. It used to be that you would round on that patient, which would take 10 minutes, then spend another 55 minutes reviewing her chart, working with the unit social worker, calling the patient’s children and filling out forms for assisted living. You’d bill a 99233 (subsequent visit) for the first 35 minutes of service, then a 99356 for the remainder. That translated into some decent work relative value units and dollars.
Unfortunately, the CMS has converted many of these services into unreimbursed care. While Medicare will still pay for the first 35 minutes of service, even if some of it is non-face-to-face, we must now have direct contact with the patient to bill for prolonged service. In the example we’ve been playing with, you can bill a 99233, but you have to forfeit the remaining 30 minutes. That represents $80 in lost revenue, or a 47% reduction. Call that the "black hole" for doctors.
Some suggested strategies
"No fair!," you protest, and I totally agree. If you can bill for only 10 minutes of direct patient contact in this case, that’s just $35 for doing more than an hour’s worth of work, which is about 50% of a hospitalist’s hourly rate.
But we’re lucky that we can still bill for some non-face-to-face services. And while some unreimbursed care is inevitable, there are a few ways to reduce the impact of this billing change.
One strategy is to complete as much of your work as possible in the presence of the patient. The main caveat is that the patient needs to be able to contribute to or directly benefit from the care delivered. Here are some examples:
- reviewing medical records with the patient;
- conducting care conferences, both live and telephonic, with the patient present; and
- completing forms and other paperwork with the patient’s assistance.
Other strategies for non-face-to-face care include:
- Chipping away at paperwork over several visits, which are billed based on time. If you do all the paperwork at once, you’re giving away your time once you exceed 35 minutes. But if you do a bit each day, you can factor that into the level of visit you bill for, based on time spent. This may help you avoid both the doughnut hole and black hole.
- Enlisting the help of support staff such as care coordinators for tasks that either don’t require a physician’s skill set or can be performed with physician supervision.
Keep in mind that frequent use of prolonged service codes invites outside scrutiny. I don’t bill them very often. Instead, I find it more practical to "chunk" various aspects of patient care over several visits and then bill those visits based on time.
David Frenz, MD, is a hospitalist for the HealthEast Care System in St. Paul, Minn., who wants to acknowledge the help of coder Susanne Linssen. Dr. Frenz is board certified in both family medicine and addiction medicine and serves as system medical director for addiction medicine. He can be reached at firstname.lastname@example.org.