Published in the June 2008 issue of Today’s Hospitalist
ONCE AGAIN, readers have plenty of questions on how to bill for everything from subsequent visits to the proper sequence for coding observation services that turn into an admission. Not only are physicians writing in, but coders and administrators are trying to figure out the ins and outs of billing for hospitalist services.
Here are answers to some of the more common questions I’ve received. Feel free to encourage staff to send in any questions they have.
I am wondering what I need to document for the history of present illness during subsequent visits. Do I have to document a past medical, family and social history and a review of systems each time?
For subsequent visits (99231-99233), document only an interval history. Payers assume that none of the patient’s past medical, family or social history has changed since admission. They also assume that if anything has changed in the review of systems, you will update that in the patient’s chart.
To determine which level of subsequent visit to code, you need to meet or exceed the requirements for only two out of three areas: history, exam or medical decision-making. Typically, the choice of which subsequent visit code to use is driven by the physical exam and the level of medical decision-making.
Can I bill a subsequent hospital care code (99232) AND a medical team conference with health care professionals code (99367) on the same day if I document them both?
Theoretically, you should be able to bill for both with the right documentation. Practically speaking, however, 99367 is a new code introduced this year, so some payers may initially deny payment for it.
Furthermore, the Centers for Medicare and Medicaid Services (CMS) does not pay for time spent in non-face-to-face services “so Medicare doesn’t pay for this code, although some private insurers might. If you provided the service, document it for medical and legal reasons. But don’t bother to bill Medicare for the 99367 service because you won’t get paid.
While supervising residents, I may spend between 30 and 40 minutes discussing (at or near the patient’s bedside) the needs and care plan of patients who aren’t critically ill. Because these encounters are so time-consuming, can I bill them with a critical care code (99291) or only as a subsequent visit?
You cannot use a critical care code if a patient isn’t critically ill. Instead, continue using subsequent visit codes. Refer to the CPT manual for the general parameters of time typically spent on admission services and subsequent visits. (See “Time requirements for typical E/M codes,” left.) If you go beyond those time parameters, consider adding on a prolonged service code if one would apply.
Where does it state in the CMS manual that patients have to be observed for eight hours before we can bill an observation code (99234-992236)?
What is the best code combination to use if a patient comes in under observation and is admitted two days later? Do we bill an observation code, such as 99219; then a follow-up outpatient code, such as a 99213, for the follow-up observation; then an admission code, such as 99222? Or do we change the 99219 to an inpatient admission code and the follow-up to a subsequent visit code?
Your first scenario is the appropriate one. Billing an inpatient admission code from the beginning of the patient’s stay would conflict with the hospital’s information on the patient’s status.
How much time do we have to go back and attach an addendum to original documentation?
I have never heard of the CMS (or any other payer) specifying a time limit for adding addendums. That said, I would be sure to send an addendum within a reasonable time of recollecting additional information.
You could refile the claim and potentially receive more reimbursement. However, adding clarity for medical and/or legal purposes, not compensation, should be the motive for selective remembering after the fact.
Patients as poor historians
If I note in the history of present illness that a patient is a poor historian, must I also repeat that in the past medical, family and social history, as well as in the review of systems?
The history of present illness, review of systems, and past medical, family and social history are all elements of the history component. Mentioning the fact that a patient is a poor historian once should be enough of a caveat to establish why you weren’t able to obtain a complete history.
Different admission dates
I am frequently called to the emergency department after 10 p.m. to admit patients. I do all the work to admit these patients on that date, but the hospital doesn’t technically admit them until after midnight. Can I bill for an initial visit on the date that it actually occurred, then bill a subsequent visit on what is, as far as the hospital’s records go, the patient’s first day?
If the hospital lists the next day as the patient’s day of admission, the payer will probably deny any billing submitted for services from the day before. Payers look to make sure that providers’ dates for admission and discharge are in sync with the hospital’s.
Instead of billing a different date, combine the work that you do during admission and your first subsequent visit and bill that on the same day that the hospital shows the patient being admitted.
Residents and discharge
When discharging a patient, can I count resident time spent in the discharge process?
This was a question that came up in my February 2008 column, and I should have been more clear that a resident’s time during discharge can be billed only if an attending is present and provides the proper attestation.
According to Medicare guidelines, time spent with a patient by a resident or fellow can be counted into a time-based discharge code only if attendings attest to their presence.
Tamra McLain is an independent coding consultant in Southern California who is available for in-house training for physicians and coders. E-mail her your documentation and coding questions at email@example.com. We’ll answer your questions in a future issue of Today’s Hospitalist.