Published in the November 2017 issue of Today’s Hospitalist
SITUATIONS THAT inevitably create billing confusion for hospitalists include how to bill and code for patients who move among different care settings, whether it’s in and out of the ICU, or from observation to inpatient status or vice versa. Here are some questions from readers that delve into billing for these kinds of changes.
Observation to admission
I read your September column (“The ins and outs of billing observation“), and I have these questions: If we originally admit patients to observation but then switch their status to inpatient the next day due to a change in their medical condition, should we bill an observation H&P the first day and then a full inpatient admission H&P the next? Our usual practice has been to just bill a subsequent inpatient visit that second day, not a new H&P.
When patients are admitted from observation on a subsequent date, the hospitalist should bill an initial hospital visit on the date of the inpatient admission. If hospitalists reference any information from the previous day’s initial observation care, they need to indicate the date of that former note as well as confirm that their findings on admission are the same.
Physicians may not bill an observation discharge on the same date as an inpatient admission.
Keep in mind that physicians may not bill an observation discharge on the same date as the inpatient admission. And of course, any documentation must support the need for the admission.
However, if patients go from observation to inpatient admission with the same physician on the same date, that hospitalist can bill only one initial visit. Inpatient services are paid on a per diem basis and should include all professional services provided to a patient on that date by one physician. Medicare views doctors from the same group practice and same specialty as a single physician.
Another scenario: A patient is admitted by the night hospitalist as inpatient rehab but then changed to observation status per case management. How do we correct our billing to reflect that change? Should we not bill the 99222 the night hospitalist put in for the admission and instead use an observation code: either 99235 (same day initial observation care and discharge) or 99219 (initial observation care)? But will that then reflect the wrong physician?
First, you may want to review with your hospitalists the criteria that patients must meet to qualify as an inpatient admission. (InterQual criteria are frequently used). That might save you some work on the back end.
When case managers change a patient’s status, you have to change the CPT code you report to get paid. The admitting hospitalist (the night hospitalist in this scenario) should change the inpatient admission code to an outpatient observation code at whatever level his or her documentation supports.
Otherwise, if the hospitalist who sees the patient for the first time in observation the next day bills initial observation care, his or her CPT code will not match the hospital’s facility bill—and it will likely be denied.
ICU to the wards
We are now being told that when a patient is transferred from the ICU to the wards under a hospitalist’s care, the receiving hospitalist could potentially bill a new charge that day, even if the critical care physician already charged one. Is that true? We were previously led to believe that because we are all in the same medical group, a hospitalist couldn’t bill on the same day as the critical care physician.
A similar situation: Say the patient was first admitted to the ICU, then transferred to the floor under hospitalist care. Would the hospitalist receiving that patient on the ward bill an initial visit because it is the first time he or she is encountering that patient? Or would that first ward visit be a subsequent visit (or extra time charge), given that the patient was seen by a member of our group when admitted to the ICU?
I’m going to assume that the doctor treating the patient in the ICU in both scenarios is also a hospitalist within your same group. If that’s the case and if any patient in the ICU has already been seen and evaluated on a given date, transferring the patient that day to the floor doesn’t mean the receiving hospitalist can bill a visit.
You may, however, be able to combine both hospitalist visits and select a level of service based on what the documentation supports.
Hospital to home
As hospitalists, we are often asked to fill out physician face-to-face documentation for home health services prior to discharge. May we use the code G0180 (physician certification of home health) when completing patients’ home health certification in the hospital, even when we won’t treat those patients as an outpatient and we won’t be the doctor executing further home health orders for them?
Hospitalists may be eligible to perform the face-to- face encounter required for home health certification, but they must meet certain criteria. The Centers for Medicare and Medicaid Services (CMS) publishes an informational booklet entitled “Medicare Home Health Benefit” (ICN 908143), dated March 2017.
Per 42 CFR 424.22(a)(1)(v)(A) of that publication, the face-to-face encounter can be performed by the following:
- a certifying physician;
- a physician who cared for the patient in an acute or post-acute facility from which the patient was directly admitted to home health;
- a nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician or acute/post-acute physician; or
- a certified nurse midwife or physician assistant under the supervision of the certifying physician or acute/post-acute care physician.
Keep in mind that, according to 42 CFR 424.22(d) (2), the face-to-face encounter cannot be performed by any physician or allowed NPP (listed above) who has a financial relationship with the home health agency.
In addition, the patient’s medical record from the certifying physician and/or acute/post-acute care facility must contain information that justifies the referral for Medicare home health services. That includes documentation that substantiates the patient’s homebound status and need for these skilled services.
Further, the clinical note in the medical record from the certifying physician and/or the acute/post-acute care facility for the face-to-face encounter must demonstrate that the encounter occurred within the required timeframe (within 90 days prior to the start of care or 30 days after the start of care), was related to the primary reason why the patient requires home health services, and was performed by an allowed provider. Typically, this information can be found in clinical and progress notes and discharge summaries.
Sue A. Lewis, RN, CPC, PCS, is a coding manager for a nonprofit health plan in the Midwest. Send your billing and coding questions to her at email@example.com, and we may answer them in a future issue.