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What’s bundled and what’s not?

Answers to questions on what you can bill separately

January 2009

Published in the January 2009 issue of Today’s Hospitalist

IT MAY BE A NEW YEAR, but there’s still plenty of confusion about coding rules and guidelines, particularly when it comes to knowing which services are part of a bundled payment and which can be billed separately.

Here are some questions I’ve received from readers on that topic, along with answers that I hope will clear up some of the confusion.

Q: I know there are codes for initiating ventilator support (94002) and for subsequent ventilator management (94003). Here’s my question: Can I bill a hospital visit and either a 94002 or 94003? I’ve heard that I can bill either a visit code or a ventilator management code, but not both.

A: You heard correctly: You can’t bill both. Payment for ventilator management is bundled into hospital visit codes and cannot be billed separately.

Q: Can our group bill for an admission and a subsequent hospital visit on the same day? Those services would be performed by two different physicians who use the same billing ID number.

A: Unfortunately, you can’t bill for both services. A subsequent visit on the same date would be bundled with the admission code. The two physicians can combine their respective times, however, and bill a higher admission code, if warranted.

Q: An emergency department (ED) doctor sees a patient in the ED and admits that patient to inpatient status. The same physician then sees the patient on the floor, acting as a hospitalist for the same ED group. How should we bill this?

A: When ED doctors serve as the admitting physician, they can bill only the admission. If they are treating a patient in the hospital who they didn’t admit, they should bill for a subsequent hospital visit. The ED visit would be bundled into either hospital service if provided by a doctor in the same group who is part of the same specialty.

Q: My question has to do with billing for perioperative care. Say a patient is having surgery and the hospitalist goes to the floor or to the outpatient surgery unit to perform either preop or postop care for the surgeon. Can we bill for that service, or is it included in the surgical package?

A: If the hospitalist is asked to give an opinion on whether a patient can undergo surgery, bill either an inpatient or outpatient consultation code, depending on the setting. A consultation would not be considered part of the global package.

According to my source at Medicare: If a consult is not being requested, a transfer of care has not occurred, and a preop service is done within the global period by another physician who is not part of the group doing the surgery, you would bill for the service as a hospital visit.

If a transfer of care has taken place, however, a routine preop exam and/or postop care could be considered part of the global period. In this situation, you would have to carve out billing for preop or postop management services by using either the preoperative modifier (-56) or the postoperative-management-only modifier (-55). (Keep in mind that Medicare does not recognize modifier -56, so just bill the service without the modifier for Medicare patients.) Use the modifier in conjunction with the surgery CPT code being billed by the surgeon.

Surgeons aren’t fond of this option because it divvies up the global payment between the hospitalist and the surgeon. The surgeon should also use modifier(s) “such as the surgical care only modifier, -54 “to represent that portion of the global period he or she performed.

More information on Medicare’s global surgery guidelines is online. The pertinent section is 100-4, chapter 12, section 40.

Q: If a patient comes in through the ED, goes for emergency surgery and then remains hospitalized, can the hospitalist perform and bill a history and physical? These patients are assigned to a hospitalist who becomes the admitting physician of record. It seems to me that when patients have had surgery prior to seeing a hospitalist, they are in the global period. Doesn’t that mean that any E&M service related to their admission after surgery would not be billable?

Another question: How should hospitalists bill for seeing patients who come to the hospital for a planned surgical procedure? The hospitalists obviously do not perform the surgery and are not the admitting physician.

A: My answer to the last question would also apply here as well. Technically, the global period applies only to the physician or physician group that performed the surgery.

If the hospitalist is not part of that group and a transfer of care didn’t occur, the global period would not apply. The hospitalists could bill for an E&M service such as a subsequent visit or a history and physical.

Q: I was somewhat confused by your article in the July 2008 issue on documenting a review of systems (ROS).

Your article states, “Using the blanket statement ‘all other systems reviewed are negative or WNL’ (within normal limits) is acceptable and will ensure that you get credit for a comprehensive review.” But we’ve been told by a coding consultant that we cannot use a blanket statement when documenting an ROS and that at least 10 systems must be reviewed.

Are you saying that we can use a blanket statement only after we have reviewed and documented 10 systems? Or can we use that statement in lieu of documenting all of the reviewed systems?

A: Sorry for the confusion. Using a blanket statement is controversial and it may be outlawed at some point. But right now, it is still acceptable.

According to CMS guidelines, you must review the system(s) directly related to the problem(s) identified in the history of present illness, plus all additional body systems (for a minimum of 10) to be able to bill for a comprehensive ROS.

You don’t need to document all of those individual 10 systems if you document “all other systems reviewed are negative or WNL.” You need to document only those findings “positive or negative “that are pertinent to the patient’s medical problems.

Kristy Welker is an independent medical coding consultant in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.