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Confused by all the company you keep?

How to bill when several doctors treat the same patient

December 2008

Published in the December 2008 issue of Today’s Hospitalist

MANY OF THE QUESTIONS I RECEIVE from readers revolve around the fact that more than one hospitalist will treat a patient on any given day, both in out of the ICU. This month’s column takes a look at some of the most common questions I receive on the topic, plus other billing and coding questions that confuse hospitalists.

Same patient, different doctors
Q: We discovered during a recent audit that sometimes two hospitalists see the same patient on the same day. How should we bill for these visits? I know that you can lump time (and documentation) together if the same provider sees a patient more than once on the same day. But how do we bill for two different providers?

A: When multiple providers see the same patient on the same day, they need to combine their time and services for one overall E/M code. Because both physicians are billing with the same practice tax ID number, they would be considered one provider and their services would not be paid separately.

When different physicians admit and discharge a patient to observation in the same day, who gets billing credit?

Same-day admission and discharge
Q: Frequently, our night shift doc admits a patient after midnight, and that same patient is discharged by one of the day docs later that same day. How do we code this?

A: Guidelines from the Centers for Medicare and Medicaid Services (CMS) specify that you need to document a same-day observation admit and discharge (99234- 99236). When it comes to billing, your group needs to set up a standard policy for which doctor “the one doing the admission or the discharge “will be credited with the entire service. Usually, credit is given to the admitting physician.

Critical care
Q: If physician A sees a patient on one calendar day and bills 99291 for the first hour of critical care service along with a 99292 (for an additional 30 minutes of critical care), can physician B bill a 99291 the next day? Or should physician B the next day bill additional hours of critical care?

Another question: If I admit a Medicare patient for critical care, should I bill a 99291 along with the HCPCS code G0390 range? Or should I use G0390 only followed by subsequent visit codes, if any?

A: First, a little explanation: The HCPCS coding system covers random codes for drugs and durable medical equipment and includes temporary codes that have not been listed in the CPT as yet.

As for your first question, physician B is rendering critical care on a different calendar day, so it would be appropriate to use 99291. But G0390 is used only to report facility codes for critical care. For professional critical care services, physicians should report either 99291 or 99292.

Q: Can we bill a critical care 99291 instead of an inpatient consult 99255 if the three “R’s” and time are included in the documentation?

A: Yes, as long as the patient was critical when the consultant saw the patient and the time spent in critical care management exceeded 30 minutes.

Outpatient vs. inpatient status
Q: How can we bill an initial inpatient hospital visit code (99221-99223) if a patient’s status is listed as outpatient, even after a hospitalist decides to admit and does the admission paperwork?

In our facility, patients are considered an inpatient only when they arrive on an inpatient floor, not if they are waiting for a room in the ED, even after a hospitalist has technically admitted them. The CPT guidelines state that the work for the overall E/M service performed in a calendar day includes work performed in another site as well as in the inpatient setting.

A: Once a hospitalist or ED physician gives the order to admit, the hospital should change the patient’s status. Any delay in doing so poses problems for submitting charges for inpatient professional services. I would suggest that you contact your hospital administrator and have this fixed internally.

Billing a pronouncement
Q: How should physicians bill for pronouncing a death? What if a hospitalist is called to pronounce on a patient whom he or she has never treated?

A: According to the CMS, a physician can bill 99238- 99239 for this service. (For clarification, see HYPERLINK “http://www.cms.hhs.gov/Transmittals/Downloads/R1460CP.pdf” www.cms.hhs.gov/Transmittals/Downloads/R1460CP.pdf.) HOTLINK URL

Prolonged services codes
Q: One hospitalist working the night shift admits a patient at 12:30 a.m., but another hospitalist completes the full exam and orders tests at 5 a.m. on the same day. Can we bill both visits for the day as an admission for the first physician and add a prolonged service visit code for the second physician? If not, how should we bill both encounters?

A: You pose an interesting scenario. I’ve discussed this with a colleague but still don’t have a definitive answer. Let me offer instead our collective opinion:

From your description, it sounds like the bulk of the work “including the initial history and physical “is being done by the second physician. Dr. A should combine his or her work efforts with those of Dr. B who is doing the billing.

If Doctor A spends more than the suggested time attached to the initial visit codes (which are 30 minutes for 99221, 50 minutes for 99222 and 70 minutes for 99223), then Dr. B could potentially bill using a prolonged services code. His or her time must be more than 30 minutes beyond the typical time spent on the history and physical to count toward the first hour of prolonged services.

Remember that physicians billing for prolonged services must document in the patient record the amount of time spent. Also keep in mind that most payers do not recognize non-face-to-face time spent.

Q: I have a question regarding CPT 99238, which is for hospital discharge. A payer recently denied payment for a 99238 for one of our patients. The patient was a newborn who had been circumcised at the hospital. The reason given for the denial is that 99238 is bundled with the circumcision code, 54150, and so is considered to be included in the global period.

A: According to my coding software, 54150 does not have any global period. This sounds like an unnecessary denial that you should appeal.

Tamra McLain is coding regional manager with MedDat 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.