Published in the May 2012 issue of Today’s Hospitalist
HERE’S A QUESTION that apparently has many of you stumped: How should you bill your services when patients are transferred to a different unit in the hospital or to an off-site facility for additional treatment, instead of being discharged home?
For an update on moving patients from one health-care setting to the next: “Patients on the move? Here’s how to bill,” November 2017
To answer that question, let me refer again to one of my favorite resources: the “Medicare Claims Processing Manual.” The issue of billing services around transfers is addressed in chapter 12, section 18.104.22.168E.
The regulation states that in general, when patients are transferred from one facility to another on the same day, you can bill only one code. That typically will be either an initial hospital care code for your group’s services at the new facility (or in the new unit) or a subsequent visit code. But Medicare then goes on to spell out several exceptions to that rule.
Under certain circumstances, physicians transferring patients may bill both a hospital discharge code and an initial hospital care code. To do so, the first requirement is that two physicians in the same group (or even the same physician) must have performed the discharge and the elements of an initial hospital care code.
The second requirement you must meet to bill for both services is that both can’t occur on the same day. And finally, the transfer must meet at least one of the following criteria:
- The transfer occurs between two different hospitals.
- The transfer is between different facilities that are commonly owned but do not have “merged records” (more on that below).
- The transfer is between an acute care hospital and a unit within that same hospital that is exempt from the prospective payment system (PPS) “again, where there are no merged records.
Definitions and caveats
Before we examine how these rules play out in billing, let’s get our nomenclature straight.
“Merged records” does not refer to sharing a common electronic health record. Instead, “no merged records” means that the acute care record is considered closed and a new record has been initiated for that patient in the new unit, facility or hospital to which he or she has been transferred.And a quick reminder: PPS refers to a Medicare reimbursement method based on a predetermined, fixed amount. The Centers for Medicare and Medicaid Services uses separate PPSs to reimburse acute care hospitals, hospice, inpatient rehab facilities, inpatient psychiatric facilities, long-term care hospitals and skilled nursing facilities, among others.
To determine how to bill, consider both the date of service and whether you meet the above transfer criteria. If you don’t meet these criteria, you can bill only the appropriate level of subsequent hospital care (99231-99233) on the date of transfer. And just to keep things interesting, Medicare makes an exception to the same-day rule when patients are transferred to a nursing facility.
According to the Medicare manual, two doctors from the same group (or one doctor if he or she is the principal physician of record on both sites) can bill both the hospital discharge (99238-99239) and the admission to the nursing facility (99304-99306) on the same day. Before we take a look at some related questions, note that some of these questions raise the issue of billing consults.
For Medicare patients and patients covered by insurers that follow Medicare guidelines, this is a moot point; Medicare, as you’ll remember, no longer recognizes consult codes.For payers that do recognize consult codes, however, refer to CPT guidelines on how to use those codes appropriately. For clarity, I’ll base my answers on Medicare guidelines that no longer recognize consult codes.
The five pulmonologists in our group make rounds at several local hospitals. On occasion, one provider will treat a patient and bill a 99233. But then the patient is transferred to another facility, and we are asked to consult at that facility on the same day. Another physician in our practice treats the patient there and bills for initial hospital care (99223). Is this right? Or should we bill the consult at the new facility as a subsequent visit as well?
Because the subsequent visit codes are “per day” codes, you cannot bill a subsequent visit code and an initial hospital care code on the same day. The exception for billing two codes on the same day is if the patient is transferred to a nursing home; in that case, if a physician in your group performed the discharge, you can bill both the hospital discharge and the nursing home admission. If the patient was not transferred to a nursing home or the transfer was to a facility that did not meet the transfer criteria, you’d be able to bill only a subsequent visit code (9923199233) for both services.
You could combine the complexity of both visits and possibly bill a higher level of visit. But if the patient is transferred to a hospital that meets the transfer criteria, your group could bill an initial hospital care code instead of a subsequent visit code. Again, you could combine the complexity of services from both visits and bill the appropriate level of initial hospital visit code.
How should we code a transfer done by two hospitalists in the same group, with one hospitalist discharging the patient and the other admitting the patient on the same day to a different hospital? (It’s a non-nursing facility.)
Again, because both hospitalist services in this case took place on the same day, you can’t bill both. You must instead combine both services into either one subsequent visit code or an initial hospital visit code (99221-99223), if the transfer criteria were met.
Our hospitalists cover two hospitals in one hospital system, and hospital “A” has a rehab unit. How do we bill if a patient we’ve followed in that hospital is discharged from the hospital and then admitted to the rehab unit, with us as consultants? And is there a difference if the patient is discharged from hospital “B” and admitted to the rehab unit at hospital “A”?
If Medicare’s transfer criteria were not met and both services occurred on the same day, you would bill a combined subsequent visit code for both services. The answer would be the same if the patient was transferred from hospital “B.”
My department has been debating how to correctly code for transfers to other hospitals. When a patient is discharged from our hospital and transferred to another hospital (not related to our facility) on the same date of service, we have been billing subsequent codes for the hospitalist’s last day of service. But some of us feel we should be coding a discharge service because the patient will not be returning to our facility. (We’re providing no services in the hospital to which the patient is transferred.)
If you are the principal physician of record and perform all the discharge elements, you should bill the discharge. That certainly yields a higher rate of reimbursement than a subsequent visit code. If you’re not the principal physician, however, a subsequent visit code is what you should bill.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and your coding questions to her at email@example.com. We’ll try to answer them in a future issue of Today’s Hospitalist.