DOES YOUR HOSPITAL have a large book of business with private insurers? If so, you may still be reporting consult codes—and trying to figure out how to split bill for those consults with advanced practice providers. Here are some of the latest coding questions from our readers.
I’m trying to figure out how to code split visits related to consults. In a previous column (“Split visits, transfers and consults,” March 2014), you wrote, “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 you are 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.”
Here’s our dilemma: We have a number of commercial payers who say they follow Medicare rules on split/shared visits, but they still recognize consult codes 99241-99245 (for office consults) and 9925199255 (initial inpatient consults). So how do we bill these consult codes? Can we share or not share?
Physician billing differs from that of facility billing, which focuses on principal diagnosis.
Sounds like you have your hands full! Rather than guessing what you should do and perhaps guessing wrong, here’s my suggestion: If you have a substantial percentage of patients with commercial insurance, I think it would be well worth your time (and perhaps save you an audit) to draft a letter to each commercial payer—a form letter works—asking each to confirm your understanding that:
• The company accepts inpatient and outpatient consultation codes.
• The company allows consultations to be billed as a split/shared visit.
At the end of the letter, consider adding a statement to the effect that if you do not receive a written response back from them in 30 days, you will assume your understanding is correct and will bill accordingly.
This gives you some measure of protection should a commercial payer come back and question or even deny bills for split/shared consults.
Physician vs. facility billing
Do doctors need to follow the same coding rules as the hospital for principal diagnosis? And can they change the codes during the patient’s stay?
We do interim billing every seven to 10 days. If a patient’s conditions change over the course of a hospital stay, the doctors keep updating the diagnoses. Can we simply keep the principal diagnosis as the condition that warranted the hospital stay at the time of admission along with the appropriate secondary codes for the entire stay?
To your question, “Can we simply keep the principal diagnosis as the condition that warranted the hospital stay at the time of admission… ,” here’s my short answer: No.
Physician billing differs from that of facility billing in that doctors are supposed to report the condition(s) or diagnoses that they are managing or treating the patient for on each date of service. Say, for example, an inpatient has had hip replacement surgery, and the hospitalist is managing that patient’s diabetes, hypertension and COPD. Those are the conditions the hospitalist would report diagnosis codes for, while the orthopedic surgeon would report the diagnoses related to the hip surgery.
And if a patient develops pneumonia in the hospital, the hospitalist would add that condition to the list of diagnoses he or she is managing, beginning on the date of service that the pneumonia was diagnosed.
It is entirely appropriate for physicians to bill this way. Facility billing, on the other hand, focuses on principal diagnosis because that is what drives the DRG payment. The ICD-10-CM coding conventions for physician billing, which offer great information about physician vs. inpatient facility coding, can be found in the ICD-10-CM Manual.
The Centers for Medicare and Medicaid Services (CMS) is now focusing on how to reduce the amount of paperwork required of physicians in what is known as the “Patients over Paperwork” initiative. In the past, if a medical student performed and documented an evaluation and management service, the teaching physician was still required to personally perform and re-document his or her own evaluation.
But as of this year, teaching physicians may now verify in the medical record any medical student documentation of the components of an evaluation and management service. Attendings must still personally perform the physical exam and medical decision-making components that are being billed, but they may verify any medical student documentation in the medical record rather than re-documenting that work. The CMS will consider that verification requirement to be met if the teaching physician signs and dates the medical student’s entry in the medical record.
For more details, see the MLN Matters MM10412R and the Medicare Claims Processing Manual 100-4, chapter 12, section 100.1.1, part B.
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 email@example.com, and we may answer them in a future issue.Published in the December 2018 issue of Today’s Hospitalist