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Split visits, transfers and consults

March 2014

Published in the March 2014 issue of Today’s Hospitalist

NOT SURE WHETHER you can bill an initial visit for a patient transferred to the floor from the ICU or how to bill a split/shared visit? Readers’ questions reflect the many types of patients that hospitalists treat, the different settings they work in and the amount of work they do with non-physician providers. Here are some of your questions and my answers.

Split/shared visits
We have a question about how to bill for a split/shared visit, where we split billing for services between a physician and non-physician provider. More specifically, we’re wondering about billing for a split/shared visit when we are transferring care for some aspects of a patient’s medical problems. We understand true consults must be billed under the mid-level’s NPI, but we’re not sure how the guidelines apply to transfer of care visits.
Transfer of care implies that a provider has been asked to assume responsibility for the care of some of a patient’s medical problems. As you mentioned, a transfer of care is not a consult.

I can’t tell whether you’re asking about an inpatient or someone in observation status, who’d be considered an outpatient, or if the patient has previously been seen by a member of your group. But here are the criteria for billing initial hospital care or subsequent hospital visits as split/ shared visits:

    • The physician and nonphysician provider splitting the visit are from the same group practice, and each personally performs a portion of a face-to-face E/M service.
    • The work performed by each must be substantive in nature. According to Medicare, a “substantive” portion of an E/M visit involves all or some portion of the history, exam and medical decision-making. You need to make sure that each does a significant amount of work in one of these three areas to qualify for a split/shared visit.
    • Each provider must personally document the work he or she delivered. The documentation must clearly indicate which part of the key components of history, exam and medical decision-making each performed.You may not bill a shared/split visit for critical care services, procedures, or for services that take place in a SNF, nursing home, or a patient’s home.

Consults are also on the list of services for which you can’t bill a shared/split visit “but that’s only the case when billing insurers that still recognize consult codes. Medicare, as you know, no longer recognizes those codes. For Medicare patients, you would bill a consult with an initial inpatient code, so billing a shared/split visit would be OK.For more information, look on the CMS Web site (www.cms.gov) under “Regulations & Guidance.” Select “Manuals”, then go to Internet-Only Manuals. In the IOM Claims Processing Manual 100-04, chapter 12, both section 30.6.1(B) and section 30.6.1(H) contain information on split/shared visits.

Transfers and consults
Say a patient is transferred from the ICU “where the initial history and physical was performed and billed by an intensivist from a different group” to the medical floor two days after the initial ICU admission. When the hospitalist sees that patient for the first time, can he or she bill a history and physical?
Hospitalists taking over patient care from an intensivist may bill only a subsequent hospital visit (99231-99233) at the level that reflects the intensity of medically necessary services. For a patient who’s already been managed in the ICU, billing an initial hospital care with a history and physical would not be considered medically necessary.

Our hospitalist is seeing a patient for a psychiatric practice to treat that patient’s medical conditions. The psychiatric group bills a history and physical. Can the hospitalist doing the consult also bill a history and physical, or is that an option for only the admitting group?
When hospitalists are asked to manage and treat the medical conditions of a patient under the care of a psychiatrist, they may bill an initial hospital visit (9922199223) the first time they see the patient. Hospitalists must clearly indicate in their documentation that the psychiatrists asked them to manage the patient’s medical conditions. In addition, hospitalists should report only those diagnoses for which they are managing the patient.

SNF visits
How often can I bill to see patients at a skilled nursing facility?
You can bill subsequent nursing facility visits once per day, as long as your documentation clearly supports the medical necessity for seeing the patient that frequently.

Critical care
Is there an ICD-9 procedure code for critical care time, 30-74 minutes?
No. You typically report critical care time as a professional service: 99291 for critical care evaluation and management, first 30-74 minutes, and 99232, critical care, each additional 30 minutes.

ICD-10
I know that according to the CMS, a hospital admission that crosses over September to October 2014 would be billed with ICD-10 codes on the discharge date. But would this also apply to hospitalists billing Medicare Part B? Or would they split the claim to cover the ICD-9 portion before Oct. 1, then bill the remainder through the discharge date with ICD-10 codes?
Based on what we know right now, hospitalists would submit claims for their professional services using ICD-9 diagnosis codes for dates of service prior to Oct. 1, 2014. Any claims submitted for service on or after Oct. 1 would need ICD-10 diagnosis codes.

E/M bell curves
Where can I find bell curves for hospital E/M service codes such as 99221-99223 and 99231-99233? I’d like to focus on cardiology, GI and a few other specialties. I can find E/M bell curves for only office visits.
You have at least two options to locate utilization data by specialty (and no, there aren’t any published utilization data for hospitalists, yet). First, you may be able to obtain these data by contacting your regional CMS office. (Go online for the address and phone number of your CMS regional office.) The CMS collects these data on a quarterly basis, but data publication generally lags between 12 and 18 months behind. The good news: E/M service data by specialty do not change significantly year to year.

Your second option is to purchase a publication that offers this information. Amazon.com has a number of titles on the topic.

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.