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Decision-making: fitting all the pieces together

How to parse out patient risk and work-ups between hospitalists and specialists

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Published in the July 2016 issue of Today’s Hospitalist

READERS SUBMITTED many questions that address a broad range of topics, but one theme emerges: How tough it is for hospitalists to figure out their own coding and billing because they work with so many other clinicians. Can hospitalists, for instance, factor in the risk of a procedure that a specialist is ordering when calculating their own level of medical decision-making? Let’s find out.

Risk and medical decision-making
A patient presented with acute renal failure and respiratory failure, so we consulted renal and pulmonary. If the patient has no other medical problems, what would be the risk of complications, morbidity and mortality?
On the flip side, another service ordered a procedure
that is considered to be “high risk.” Can we consider 
that when calculating risk in our own level of decision-
making?
You are referring, of course, to one component in determine the complexity of medical decision-making. As you know, the level of service you assign to an evaluation and management (E/M) service must be based on the key components of history, examination and medical decision-making.

Your level of decision-making should reflect the efforts required to treat the problems you’re responsible for.

With decision-making, you need to weigh these three elements: the number of diagnoses or management options you need to consider, the amount and/or complexity of data you need to review, and the patient’s risk of complications and/or morbidity and mortality. Medical decision-making comes in one of four levels: straightforward, and low, moderate, and high complexity.

Select your level of decision-making based on the clinical effort required on your part to evaluate and treat the problem(s) you are responsible for.

You cannot incorporate the risk of a test or procedure that another clinician has ordered into your level of decision-making—unless that test or procedure directly influences how you plan to evaluate and treat the patient.

If a specialist is managing a specific problem, it may well be the case that you as the attending physician may have only minimal risk to factor in when determining your own level of medical decision-making.

Decision-making and additional work-up
When we bill for “new problem with additional workup,” is that just limited to our own additional work-up? What about an additional work-up that another service is going to order, such as an ERCP?
This question refers to another component of medical decision-making: assessing the number and nature of diagnoses and management options.

Is “new problem with additional work-up” just limited to your own provider’s work-up? Yes, it is. Only the physician ordering the “additional work-up” can include it as a contributing factor under the number of diagnoses or management options component of medical decision-making.

You can, however, consider the decision to call in a specialist for a consult when calculating points for the number of diagnoses or management options.

Consults and medical necessity
We provide a psychiatric history and physical for our psych colleagues. As admitting physicians, they bill a psych evaluation code. How should we bill these H&Ps if patients overall are medically healthy except for a psychiatric diagnosis or exacerbation, such as a psychotic episode with suicidal intent?
Payment for most services under Medicare, Medicaid and many commercial plans is based on medical necessity. So here’s my question: Are these medical evaluations medically necessary?

They certainly would be for psychiatric patients with known medical problems, or if a psychiatric provider plans to start a patient on a new medication and needs a baseline medical evaluation because of the risk of potentially serious side effects. In such cases, your psychiatric colleagues should document that they are requesting a medical evaluation for that specific purpose. That documentation would support the medical necessity of the request.

But if psychiatric providers are asking hospitalists to routinely provide a medical evaluation for every patient, regardless of age or health status, I think it would be fairly easy to question the medical necessity of those services, especially if a payer conducted a post-payment audit. (For more on medical necessity, see my August 2014 column, “Medical necessity, or medically necessary?”)

To your question: When providing appropriate evaluations, you and your colleagues could bill initial hospital care (99221–99223) if it’s your first visit with that patient and if you meet criteria for initial hospital care, or a subsequent hospital care code (99231–99233).

Chronic illnesses
Some of our patients have chronic illnesses that we are comanaging, such as orthopedic patients with well-controlled diabetes, hypertension and hypothyroidism. We are continuing their home medications. What can we bill for providing this comanagement?
The Internet-Only Medicare Claims Processing Manual 100-04, chapter 12, section 30.6.9, section C provides clear guidance on when payment is allowed for services provided to a single patient on any given date. The CMS takes the position that it is not medically necessary for two physicians to manage the same problems or conditions on the same date of service for the same patient.

If an orthopedic surgeon asks a hospitalist to manage the chronic illnesses of a post-op total hip replacement patient, the hospitalist can bill either an initial visit (if he or she is seeing the patient for the first time) or a subsequent visit for that management. But if the orthopedic surgeon is also managing that patient’s diabetes and hypertension, both providers cannot be paid.

Assuming the orthopedist is not managing those conditions, the patient would still need medical oversight even if his or her conditions are well-controlled and the hospitalists are only continuing the home medications. Hospitalists would, for instance, have to order the patient’s medications and adjust dosages based on the patient’s post-op condition.

How do you assess risk?
WHEN DETERMINING your level of medical decision-making, one factor in the calculation is a patient’s risk of significant complications, morbidity and/or mortality. Make that assessment based on the answer to these three questions:

  • What risk does the disease process or medical problems present between today’s visit and the next?
  • What risk is present either before or immediately after any diagnostic or therapeutic procedures are performed?
  • What is the risk associated with the treatment options selected?

Sue A. LewisSue A. Lewis, RN, CPC, PCS, is a coding manager for a nonprofit health plan in the Midwest. Send any billing and coding questions you have to her at slewis56@q.com and we may answer them in a future issue.