Published in the June 2009 issue of Today’s Hospitalist
THE QUESTIONS READERS SEND IN reflect the many services that hospitalists provide, from critical care to consult requests and observation and discharge services. Here are answers to several of your most recent questions:
Consults
Q: Regarding consultations, I understand that the requesting provider must include the name of the requested consultant and that the consultant must state who made the request. Does the requested consultant need to be named individually, or can a more generic request “for “hospitalist,” “GI” or other specialist “be used instead, with the idea that the requested group will then delegate the consult to a specific provider?
And can either the requestor or the consultant be a non-physician such as a physician assistant or nurse practitioner? Or should the name of the supervising/collaborating physician be used instead of the midlevel’s or in conjunction?
A: When you are the consultant, you must document the name of the specific requesting physician; that practitioner’s national provider number goes in box 19 on the CMS 1500 form or in a similar field for electronic transmission. Payers do not accept claims that just list a general specialty for the source of a request. A midlevel may be the provider of record requesting a consult, but according to CPT guidelines, the consultant must be a physician.
If you are requesting a consult, on the other hand, you may document only the specialty you’re requesting, not an individual physician. It’s the consultant’s responsibility to document that you asked for the consult.
Transfers
Q: In our hospital, the intensivists “who work for a separate group “follow patients during their ICU stay and then transfer care to us on the floor, where we bill 99231-99233 for subsequent visits. May we bill a subsequent visit on the same day that the patient is transferred, even though the intensivist is already billing a follow-up visit that day?
A: Yes, you may, because you belong to separate groups. If you and the intensivists shared the same tax identification number, however, you would combine your documentation for the various follow-up visits on that date and bill one subsequent visit.
Subsequent care
Q: Can critical care services (99291-99292) be charged in a subsequent care setting, such as a long-term acute care facility or nursing home?
A: Yes, you can bill critical care in such settings. To bill critical care codes, remember that those services must meet medical-necessity requirements and take more than 30 minutes.
Cardiac monitoring
Q: As a hospitalist, am I allowed to bill for cardiac rhythm monitoring with the appropriate diagnoses? If so, how do I know which of the 93224-93237 codes (cardiographic continuous 24-hour monitoring) is the right one to use?
A: 93224-93237 are telemetry-monitoring cardiology codes used to describe outpatient services in which a physician sends patients home with some kind of cardiac monitor such as a Holter. Physicians would choose the code based on the amount of time the patient was monitored and the type of monitor used.
So far, I have not seen any of these codes used in the inpatient setting, and I don’t think it would be appropriate for a hospitalist in, say, an observation or chest pain unit to bill for this service. Instead, this type of monitoring falls into the medical decision-making factor for evaluation and management (E/M) codes. If warranted by severity and with the required amount of time, critical care codes might also be an option.
Different doctors, different care
Q: If hospitalist A admits a patient and hospitalist B (who’s in the same group, same specialty) provides critical care later that day, should we bill for each doctor’s services individually “and if those separate bills are denied, should we appeal? And when do we use the -25 modifier when submitting bills for multiple services?
A: When physicians in the same group first perform an admit and then critical care, you should use a -25 modifier (separate and identifiable service performed) on the admit. If services are performed by two separate doctors within the same group, submit separate claims listing each respective physician.
Observation services
Q: Have you heard the term, “outpatient in a bed”? Is this an acceptable form of status to use instead of observation?
A: I have not run across this term, although it appears to describe observation services. The documentation for such a patient must make it clear that this is not a regular admit, and you should bill for your services with a different set of CPT codes.
For observation patients admitted and discharged on the same calendar day, use 99234-99236. For those admitted and discharged on different calendar days, bill 99218- 99220. When discharging on a subsequent calendar day, remember to bill 99217 for the discharge service.
Billing for procedures
Q: May we bill for an E/M service on the same date as a procedure?
A: Yes, hospitalists can appropriately bill for both an E/M service “whether for a new or existing patient “and a procedure. Usually, hospitalists’ patients have many chronic conditions. While doing a procedure, doctors typically have to spend time on an exam and on medical decision-making related to patients’ other conditions.
When performing a procedure, you need to know if it’s classified as a minor or major surgery. Major surgeries, which would include inserting a chest tube, for example, come with a 90-day global billing period. E/M services performed during that period should be billed with a -57 modifier (decision for surgery). The global period for minor surgeries ranges from zero to 10 days, and any E/M services billed should have a -25 modifier (separate and identifiable service performed).
Discharge services
Q:Can any physician other than the attending bill discharge codes (99238-99239)?
A: Yes, CPT states that any physician who performs the discharge service can bill any of these codes. Typically, the attending physician does the discharge, but another physician may have to perform the service, given shift changes and scheduling. Usually, that other physician would be someone in the hospitalist group, unless the group has transferred care to another specialty during the hospital stay.
Tamra McLain is client service manager with MedData 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.
