Published in the July 2015 issue of Today’s Hospitalist
WANT TO BILL BOTH critical care and initial care on the same day? Can you bill for all the time you spend on a computer documenting? Let’s take a look at these and other questions from readers.
Critical care and admissions
Say a patient is being admitted and meets the criteria for critical care. Can the physician bill both the admission and critical care, as long as the hospitalist subtracts the time spent doing the admission from the critical care time reported?
Great question, as there are circumstances where it’s appropriate to bill both an initial inpatient visit and critical care services on the same day. But I’d urge you to proceed with caution.
First of all, the components of decision-making involved in providing critical care services and an admission are apples and oranges. As the “Medicare Claims Processing Manual” 100-4, chapter 12, section 30.6.12 spells out, “Critical care involves high complexity decision-making to assess, manipulate and support vital system functions to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”
Initial hospital care, on the other hand, requires performing and documenting a comprehensive history and exam and highly complex medical decision-making. At first glance, it doesn’t seem realistic that a hospitalist providing critical care could stop those services, do an initial admission and then resume critical care. And the part of your question about subtracting the time spent doing the admission strikes me as very risky.
However, another section of that same manual (chapter 12, section 30.6.9) sheds some light on the topic: “When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the Critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service.”
So hospitalists treating patients who are first admitted and then crash in the hospital and need critical care services can bill for both. But it doesn’t sound like that’s the case for your patient, who met the criteria for critical care on admission.
There is, however, one caveat: Critical care is a time-based code (and physicians must surpass a 30-minute threshold before they can even start the clock on billing critical care services). But the time doctors bill for critical care can be either continuous or, as the CMS puts it, “intermittent in aggregated time increments” spread out over a calendar day.
So the hospitalist in your case may have seen the patient in the ED and provided critical care services. The patient may then have stabilized and been sent to the ICU, where the hospitalist did an initial hospital visit (99221’99223). But hours later, the patient may arrest and the hospitalist provides more critical care services. All the time spent throughout the day on critical care (minus 30 minutes) should be added up and billed “and you can bill the admission as well.
I don’t find any current National Correct Coding Initiative edits that preclude these two services being billed together. (Among other things, these edits identify code pairs that typically are not billed together.)
But the CMS and those in the Recovery Audit Contractor (RACs) program closely scrutinize both these services because of their higher payment value and documentation requirements. Going back to 30.6.9, here’s what the CMS has to say: “Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims.”
So physicians need to clearly document what they did in terms of both services and how long those services took. It never hurts to add a little more detail to help auditors understand the rationale for why you are billing two separate services on the same day.
What counts for prolonged care?
Can time spent on electronic charting be counted toward subsequent care, even if it is not face-to-face? And when is it appropriate to bill the prolonged service code 99356? Can you bill that code if it takes a physician more than 30 minutes to look through old records on day 2 or 3 of a hospital stay? Can doctors bill that code if they are working away from the patient at a computer not in the patient’s room?
I’m assuming your question refers to electronic documentation for inpatients.
As for your first question: You bill E/M services based either on time or the performance of a required number of key components. But charting after a visit is already factored into an E/M service, so it cannot be used to select a level of service.
As for prolonged care, Medicare requires that the time billed be spent face-to-face with the patient. Reviewing old records is considered medically necessary and/or clinically appropriate only if the patient, the patient’s health care surrogate or power of attorney or other patient-appointed resource cannot provide important historical information that the physician needs to treat the patient.
Typically, record review is considered the standard of care. Hospitalists taking over for a colleague who’s gone off service may have to spend time reviewing records to get “caught up,” but I’d be concerned about questionable billing practices if a hospitalist caring for a patient bills 30 minutes or more of record review on day 2 or 3 of a hospital stay.
To answer your question: Record review wouldn’t count toward billing direct prolonged services for Medicare. And as for factoring working at a computer away from a patient’s room into prolonged-care time, the answer is no, at least for Medicare. Again, prolonged care must be face-to-face.
But some commercial plans may allow you to bill prolonged care in accordance with CPT guidelines, which differ from Medicare’s; CPT, for instance, allows you to bill unit or floor time for prolonged care codes. But you may want to apply only one set of standards across all your payers. That can be less confusing, and your physicians won’t have to bill based on patients’ insurance.
Billing resident services
My question regards billing commercial insurers for services performed by residents. Do we have to put the resident’s name on the claim? Or can we just bill the rendering and supervising doctor as one?
The “teaching physician rules” are specific to Medicare, and commercial carriers may have different rules. Check with that commercial plan to see what rules apply.
Under Medicare, when a resident provides inpatient care, submit the claim under the teaching physician’s name and NPI number “and append the GC modifier to indicate that a resident provided the care. But when qualified residents are moonlighting and working outside their residency program, bill their services under their own name and NPI.