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How to bill for critical care and dual services

Plus, coding and billing for short-stay admissions

January 2013
coding-tips

Published in the January 2013 issue of Today’s Hospitalist

WITH SO MANY HOSPITALISTS providing some critical care, it stands to reason that many of you have questions about how to bill for critical care services. Here are a few questions from readers, with my answers, about billing for critical care and for other services that hospitalists provide.


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Teaching requirements
Presently, my colleagues are pressing to sign off on a resident’s note and then bill critical care codes (99291-99292). But according to my interpretation of guidelines from the Centers for Medicare and Medicaid Services (CMS), we cannot do so unless we spend continuous time at the critical care bedside with residents. (As I read it, both the resident and attending must spend 30-plus minutes at the bedside discussing each patient to be able to bill a 99291.) Currently, none of my colleagues is having this kind of bedside discussion with residents. Are they risking audits and loss of revenue, or am I being overly cautious?

A couple of things: First, critical care time does not need to be continuous. However, both critical care codes (9929199292) are time-based. That means that teaching physicians can include “and bill for “their time only if they are present for the critical care service being provided.

You should not bill critical care time put in by residents without a teaching physician, even if you reference a resident’s note in your documentation. That does not meet guideline requirements “and yes, your colleagues would be at risk for those charges if audited.

Here’s the chapter and verse (“Medicare Claims Processing Manual,” chapter 12, section 100.1.4 on time-based codes): “For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. For example, a code that specifically describes a service of from 20 to 30 minutes may be paid only if the teaching physician is physically present for 20 to 30 minutes. Do not add time spent by the resident in the absence of the teaching physician to time spent by the resident and teaching physician with the beneficiary or time spent by the teaching physician alone with the beneficiary.”

Dual services
I have a question about billing for two separate services on the same day. In a former article, you wrote, “Keep in mind that Medicare does allow you to bill both critical care codes and an inpatient hospital service performed on the same day, if the patient becomes critical after the inpatient hospital care has been rendered.” So I assume we can bill both services if the first visit was, say, a subsequent visit (99233), and then later that day the patient required critical services. But what if the patient was seen in the morning by one physician who coded a 99291 (critical care, first 30-74 minutes) and later that same day by another physician in the same group, who wanted to document and bill a 99233 (subsequent visit code)? May our group bill both?

The claims processing manual (chapter 12, section 30.6.12 H) states that Medicare will pay for critical care services performed after a hospital E/M service. However, it doesn’t specifically address critical care services performed prior to such a service. (This same section also states that you cannot bill for an ED service in addition to critical care on the same date.)

But the manual does include this statement: “Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.”

Based on that paragraph, here’s my opinion: If you have two separate inpatient hospital events that are supported by documentation and meet the guidelines for both services, you should be able to bill both. But I’d also advise you to check with your local Medicare carrier to make sure you meet its guidelines.

Say an ED physician is also the hospitalist. He or she places patients either in observation or admits them. Is the doctor then allowed to choose whether to bill an ED E/M code or an admission code (or observation code, depending on the individual patient’s status)? I’m trying to find out if the doctor can choose to bill the code that pays the best.

One physician cannot bill for both ED E/M services and an inpatient or observation admission for the same patient. So if the physician first treated the patient in the ED and then admitted the patient to observation or as an inpatient, he or she can bill only one of those services. In fact, the codes for either the observation or inpatient hospital admission come with a higher reimbursement than an ED visit.

Consult vs. observation codes
A hospitalist is called to the ED to see a non-Medicare patient whom the ED doctor has already placed in observation status. The hospitalist is asked to evaluate and assess whether the patient needs to be admitted. Should the hospitalist bill one of the outpatient consult codes (99241-99245) or the office or other outpatient codes (99201-99215) for that assessment? And if the hospitalist then sees the observation patient again on the next day, which code set should he bill? Subsequent observation care codes (99224-99226)?

If the hospitalist’s services meet consultation guidelines, he or she can bill the outpatient consultation codes (9924199245). (This assumes that the patient’s private payer hasn’t followed Medicare’s example and done away with consult codes.) But if the hospitalist doesn’t meet those guidelines or provides an additional service on the following day of observation, he or she should bill office or other outpatient service codes (99201-99215). It would not be appropriate for the hospitalist to use the subsequent observation codes (99224-99226) because those are reserved for the physician who admitted the patient to observation.

Short-stay admissions
My hospital is asking me to bill for inpatients even when patients stay less than 24 hours. The patients qualify for inpatient status based on Milliman Care guidelines, but most get discharged within two or four hours. I am really reluctant to bill inpatient codes for such patients.

According to Medicare guidelines, you may use the initial hospital care codes (99221-99223) for patients admitted to inpatient hospital care for less than eight hours on one calendar date. But you should not bill a discharge code, and you shouldn’t use the observation or inpatient care service codes including admission and discharge on the same date (99234-99236). Medicare requires that patients stay a minimum of eight hours before you can bill that code set.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist..