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How to bill with two doctors on the case

April 2012

Published in the April 2012 issue of Today’s Hospitalist

THE FOLLOWING CASE is from the Today’s Hospitalist Coding Challenge, which can be found on the Today’s Hospitalist Facebook page. We asked Facebook readers to review a case and choose among four different billing options. Here’s the case, as well as responses that readers submitted online to the challenge:

Ms. Smith, an 82-year-old African-American female, presented to the emergency department by ambulance after falling on some ice. She was found to have a femoral neck fracture and was admitted under the care of the hospital medicine service. Orthopedic surgery was performed without complication on hospital day 2. Her past medical history is significant only for systemic hypertension, which is well-controlled on hydrochlorothiazide.

Ms. Smith’s postoperative course was unremarkable until hospital day 4, when palpitations woke her at 3 a.m. An electrocardiogram demonstrated atrial fibrillation with rapid ventricular response. The nocturnist saw the patient, placed her on continuous telemetry and instituted appropriate medical therapies.

Her usual hospitalist saw her later that morning. Although atrial fibrillation persisted, her rate was controlled.

How would you bill?

1. Each physician submits separate charges for the work performed.
2. Only the nocturnist submits charges because he was the first physician to see the patient on the day of service.
3. Only the patient’s usual hospitalist submits charges, as she was the last physician to see the patient on the day of service.
4. The physicians consolidate their work into a single charge for that day of service.

Online comments on the case showed a range of opinion. One participant said that the nocturnist should submit one charge for treating the patient’s atrial fibrillation while the day hospitalist should charge for a follow-up visit. Another suggested that the usual hospitalist could charge for a follow-up visit only if the nocturnist billed a critical care service.

Someone else wondered whether both physicians work for the same group, because that would affect their coding. The moderators of the case pointed out that the physicians are partners and work in the same group, with both submitting charges under the same tax ID number.

    • Reader response: “If they’re in the same group, the doctors can submit only one charge for the same calendar day. Are they in the same group/same specialty?”
    • Reader response: “The nocturnist will submit a charge for treating the patient for her atrial fibrillation and the hospitalist will charge for the follow-up visit.”
    • Reader response: “If the nocturnist submitted a critical care charge, the usual hospitalist can charge for a subsequent hospital visit (99231-99233).”
    • Reader response: “Submit the highest charge of the day, probably the afib with RVR charge.”
    • Reader response: “If the nocturnist saw her after 12 a.m. and the day hospitalist saw her on the same date, the two services can be combined for a higher level of subsequent care visit.”

Option 4 “the physicians should consolidate their work into a single charge “is correct. At age 82, Ms. Smith is a Medicare beneficiary. Chapter 12, section 30.6.5 of the CMS’s Internet-only “Medicare Claims Processing Manual” indicates that Medicare views physicians in the same group and same specialty as a single physician.The nocturnist and hospitalist both saw Ms. Smith on the same calendar day and for the same problem (new onset of atrial fibrillation). They should select a level of the subsequent hospital visit CPT code based on the key components of history, exam and medical decision-making and on the combined documentation from both visits. (Any visit from the orthopedic surgeon would be billed as a postoperative visit and would be included in the global surgery payment.)

PARTICIPATE IN NEW CODING CHALLENGES and view older ones at www.facebook.com/Todayshospitalist. Look for the “Coding Challenge” icon “and congratulations to Lori Bettencourt, CPC, PCS, assistant director of operations for Pro-Medbill LLC, in Hampton, N.H., who won a prize for participating. Her name was randomly picked from all the respondents who answered correctly. The Today’s hospitalist Coding Challenge is moderated by David Frenz, MD, a hospitalist, and Sue A. Lewis, RN, CPC, PCS, a compliance consultant. Both are with HealthEast Care System in St. Paul, Minn.