Subsequent hospital care, also known as daily care, presents a variety of daily-care scenarios that cause confusion for billing providers.
Subsequent hospital care codes are reported once per day after the initial patient encounter (e.g., admission or consultation service), but only when a face-to-face visit occurs between provider and patient.
The entire visit need not take place at the bedside. It may include other important elements performed on the patient’s unit/floor such as data review, discussions with other healthcare professionals, coordination of care, and family meetings. In addition, subsequent hospital care codes represent the cumulative evaluation and management service performed on a calendar date, even if the hospitalist evaluates the patient for different reasons or at different times throughout the day.
Traditionally, concurrent care occurs when physicians of different specialties and group practices participate in a patient’s care. Each physician manages a particular aspect while considering the patient’s overall condition.
When submitting claims for concurrent care services, each physician should report the appropriate subsequent hospital care code and the corresponding diagnosis each primarily manages. If billed correctly, each hospitalist will have a different primary diagnosis code and be more likely to receive payment.
Some managed-care payers require each hospitalist to append modifier 25 to their evaluation and management (E/M) visit code (99232-25) even though each submits claims under different tax identification numbers. Modifier 25 is a separately identifiable E/M service performed on the same day as a procedure or other E/M service. In this situation, Medicare is likely to reimburse as appropriate.
Payment by managed-care companies is less easily obtained: Payment for the first received claim is likely, and denial of any claim received beyond the first claim is inevitable. Appealing the denied claims with documentation for each hospitalist’s visit on a given date helps the payer understand the need for each service.
When concurrent care is provided by members of the same group practice, claim reporting becomes more complex. Physicians in the same group practice and specialty bill and are paid as though to a single physician. In other words, if two hospitalists evaluate a patient on the same day (e.g., one hospitalist sees the patient in the morning, and another one sees the patient in the afternoon), the efforts of each medically necessary evaluation and management service may be captured.
However, the billing mechanism used in this situation varies from the standard. Instead of reporting each service separately under each corresponding hospitalist’s name, the hospitalists select subsequent hospital care code 99231-99233 representing the combined visits and submit one appropriate code for the collective level of service.
The difficulty is selecting the name that will appear on the claim form. Solutions range from reporting the hospitalist who provided the first encounter of the day to identifying the hospitalist who provided the most extensive or best-documented encounter of the day. For productivity analysis, some practices develop an internal accounting system and credit each hospitalist for their medically necessary joint efforts. The latter option is a labor-intensive task for administrators.
Physicians in the same group practice but different specialties may bill and be paid without regard to their membership in the same group. For example, a hospitalist and an infectious disease specialist may be part of the same multispecialty group practice and bill under a group tax-identification number, yet qualify for separate payment.
This is permitted if each physician has a differing specialty code designation. Specialty codes are self-designated, two-digit representations that describe the kind of medicine physicians, non-physician practitioners, or other healthcare providers/suppliers practice. They are initially selected and registered with each payer during the enrollment process.
A list of qualifying specialty codes can be found at www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/SpecialtyCodes2207.pdf.
Hospital inpatient situations involving physician coverage are complicated. If Dr. Richards sees the patient earlier in the day and Dr. Andrews, covering for Dr. Richards, sees the same patient later that same day, Dr. Andrews cannot be paid for the second visit.
Subsequent hospital care descriptors emphasize “per day” to account for all care provided during the calendar day. Insurers treat the covering physician as if he were the physician being covered. Services provided by each are handled in the same manner described above.
If each hospitalist is responsible for a different aspect of the patient’s care, payment is made for both visits if:
- The hospitalists are in different specialties and different group practices;
- The visits are billed with different diagnoses; and
- The patient is a Medicare beneficiary or a member of an insurance plan that adopts Medicare rules.
There are limited circumstances where concurrent care can be billed to Medicare by hospitalists of the same specialty (e.g., an internist and a hospitalist, one with significant and demonstrated expertise in pain management).
Each hospitalist must belong to a different group practice and submit claims under different tax identification numbers. The patient’s condition must require the expertise possessed by the “sub-specialist.” Payment will be denied in the initial claim determination. But formulating a Medicare appeal with documentation from both encounters can demonstrate the medical necessity and separateness of each service and help earn reimbursement—although it is not guaranteed.
Managed-care payment for two visits on the same day by physicians of the same registered specialty (e.g., internal medicine), regardless of sub-specialization, is highly unlikely. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.