Home By the Numbers Patients staying beyond discharge? How to bill

Patients staying beyond discharge? How to bill

Plus, time-based billing for critical care, advanced care planning

October 2018

Published in the October 2018 issue of Today’s Hospitalist

HOW DO YOU BILL a discharge when patients don’t leave the same day the discharge service is performed? Here are answers to questions we’ve received from readers.

Discharge billing
I am under the impression that when a discharge date is set, a discharge summary should be dated the same day the discharge order is written. But if the patient stays another day for a nonmedical reason—insurance problems or no ride home—and a physician sees that patient on that additional day, he or she wouldn’t be able to bill any services. My understanding is that doctors can bill a subsequent visit for an additional day only if a patient remains in the hospital for a medical reason such as a fall or for medication adjustments.

My questions: If a patient stays in the hospital beyond the initial discharge date for either a nonmedical or medical reason, what day should we bill the discharge? The day the patient was originally supposed to be discharged or the day the patient actually leaves?

You need to bill hospital discharge services on the date the face-to-face discharge service was performed.

And what’s the rule for billing physician services on the additional day(s)? One of our doctors believes we should be billing subsequent visits until the day the patient actually leaves and then bill a discharge, even if the patient stayed for a nonmedical reason.

You need to bill hospital discharge services on the date the face-to-face discharge service was performed, even if the patient does not leave that day. If you want a reference to share with your doctors, steer them to the CMS Claims Processing Manual 100-4, chapter 12, section 30.6.9.2, sub-section B, which provides those details.

If the patient remains in the hospital for nonmedical reasons (waiting for an available bed, for example, at a nursing facility) after the discharge is performed, the attending physician can continue to see the patient. But he or she shouldn’t bill any additional visits because there are no medically necessary reasons for those.

However, if the patient develops a medical problem— fever, vomiting—after the discharge has been performed and has to remain in the hospital, the attending physician should bill a subsequent hospital care visit at the appropriate level for each date of service. It would be OK to bill the discharge for the date the discharge service took place, as well as a subsequent visit the next day.

As for when you should cancel an original discharge: only if a patient’s condition suddenly takes a turn for the worse and it becomes medically necessary for him or her to stay as an inpatient.

Critical care time
Here’s an issue our hospitalists go back and forth about all the time. One physician documents critical care and spends a total of 50 minutes with a patient. Another doctor the same day also bills critical care for the same patient for 60 minutes. The first sees the patient in the morning, while the second sees the patient that night.

Can we bill both visits on the same day? Some of us believe the first doctor should bill a 99291, while the second should bill a 99292. But I don’t think we can bill two critical care visits on one calendar date.

A couple of things: First, just because a patient’s condition may qualify him or her for a critical care visit in the morning doesn’t mean it qualifies him or her for a second critical care visit later that day. Be sure your physicians understand what qualifies as critical care: “a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”

Next, although you didn’t say so, I assume both doctors are in the same group and specialty and bill under the same tax ID number. If that is the case, the total time spent providing critical care on the same calendar day is what drives the codes billed. You should report CPT code 99291 for the first 30–74 minutes of critical care time spent, then bill code 99292 for each additional 30 minutes after that 74-minute threshold is reached.

But be sure there is a medically necessary reason for a patient to receive two visits in one day. You shouldn’t be billing a second visit, for example, if a patient’s condition is stable and no new concerns have arisen since the first visit that day. If, however, there is a medically necessary reason for a second visit on the same date but the patient does not meet criteria for critical care services, the second hospitalist could bill for a subsequent visit.

Advanced care planning
Should palliative care providers use the appropriate E/M code plus a 99497 or 99498 (advanced care planning) every time they see a patient? If not, what are the criteria for assigning the additional 99497 or 99498?

Advanced care planning codes are used to bill for services done when a physician discusses with a patient, family member(s) and/or health care surrogate what a patient’s wishes may be for medical treatment (typically in the future) when his or her decision-making capability may be compromised by illness or injury.

Billing advance care planning services are, like critical care services, time-based. Use CPT code 99497 to report the first 30 minutes of face-to-face discussion, then CPT code 99498 for each additional 30 minutes. So if a palliative care provider spends 65 minutes with a patient or family, he or she should report both a 99497 and a 99498.

You can bill 99497-99498 on the same day as other E/M services. (Refer to the CPT Manual for a list of eligible E/M codes.) But you can’t report these codes every time a patient is seen.

At the same time, clinicians can provide advance care planning services multiple times for a patient in any given time period. This usually occurs when the status of patient’s health substantially changes or if the patient wants to change end-of-life decisions that may already be in place.

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

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