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Coding for consults and readmissions

ICD-9 coding tips for consults and readmissions, with modifiers for subsequent visits to multiple physicians

September 2010

Published in the September 2010 issue of Today’s Hospitalist

CONFUSED ABOUT HOW TO CODE a readmission or whether to wait until a patient is discharged to bill for your services? Those are just two of the questions I’ve received this month from readers. Read on for my advice.

Today’s Hospitalist’s Coding articles provide hospitalist physicians the practical tips they need to thoroughly document their services and maximize their reimbursements.

I am wondering how to bill a patient’s readmission. The patient was discharged in the morning but readmitted that afternoon. Which services should we bill for the discharge and then the admission when they both occur on the same calendar date?

If the patient returned with the same condition, I recommend avoiding the discharge and admit codes. Instead, combine both levels of service in a subsequent visit code (99231-99233) based on the level of history, exam and medical decision-making.

If the patient had an entirely new condition that caused the new admit, then follow through with a whole new H&P work-up and bill the initial hospital visit code (99221-99223), as well as for discharge services earlier that day. Payers won’t be happy seeing a discharge and an admit on the same day, but if you submit the appropriate documentation showing that the patient needed to be admitted for a new diagnosis, you should avoid being hassled (or denied).

When to bill?
Should hospitalists bill their portion of a hospitalization when we see the patient, or should we wait until the patient is discharged?

Either way works. Some groups hold billing until the hospital stay is completed, especially if patients stay a week or less. For longer hospitalizations, you may want to bill for services already completed so you don’t hold up the reimbursement process.

Hospitalist codes
Is there a source that shows the most common codes that hospitalists use?

I haven’t seen any source document that specifically lists them. However, here are the CPT codes that, in my experience, hospitalist groups use most frequently:

  • Initial hospital visits (99221-99223)
  • Subsequent hospital visits (99231-99233)
  • Discharge services (99238-99239)
  • Critical care services (99291-99292)
  • Inpatient consultations (for non-Medicare patients) (99251-99255)

Working with residents
Say a patient is admitted at 10 p.m., when the resident team sees the patient, writes an H&P and does all the orders. I see the patient the next day, review the resident note and H&P, make corrections where appropriate, and independently (and personally) perform key portions of the H&P myself. Do I submit my charges as an initial visit on the day I see the patient, or use a subsequent visit code? I know I can’t bill for services on a day when I don’t see the patient, but I want to be reimbursed for the H&P I do.

Submit the H&P as an initial visit (99221-99223) on the day you see the patient under your name and number.

We often debate how to code for a consultation requested by a surgeon following a patient’s inpatient surgery. One of the physicians from our team performed the patient’s outpatient H&P medical clearance within seven days of the patient’s surgery.

We code that H&P with an outpatient consultation code (99241-99245) unless it’s a Medicare patient. For visiting the patient after the surgery, should we use inpatient consult codes (99251-99255) “unless it’s a Medicare patient, in which case we’d use subsequent visit codes? Or should we just use inpatient subsequent visit codes for all patients because we do have the H&P dictation available?

To code visits after an inpatient surgery, use the subsequent visit codes (99231-99233), even for patients not covered by Medicare.

Using the -25 modifier
I am writing about one of your replies in the March 2010 column (“Uncompleted procedures? Here’s how to bill.”). The question was how to bill for both critical care services and a subsequent visit on the same day for the same patient seen by two different physicians within the same group.

You claimed that the group should use the modifier -25 with the subsequent visit E/M service code to signal the fact that it was a separately identifiable service. However, that contradicts the AMA’s definition of modifier -25, which states the following:

“Significant, separately, identifiable evaluation and management service by the same physician on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.”

I have heard arguments for using the -25 modifier in both cases: for services provided by only one physician and also for multiple doctors within the same practice. And I understand how important it is to follow literal definitions.

However, the reimbursement process is a collision of three very different worlds. First, there’s the clinical world in which the practitioner is trying to offer the best care possible and document as such.

Second, there’s the coding world in which that documentation is filtered through an imperfect language of codes to represent what was done. Third, there’s the billing world in which each government and commercial payer and state can mandate various rules for how clinicians get paid.

Because both doctors in that original scenario are part of the same practice and use the same tax ID number, I’m fine sticking with my original answer. I’ve used the -25 modifier in just this situation for multiple physicians within a group, and I’ve never had any problems with those claims. You do need to use the modifier, though, to show the payer that there is a reason both services should be paid.

tamaraTamra McLain is client services 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.