Practice Economics

Document Inspection


 

One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.

If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Discharge Day Management

Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

Reminder: Prolonged Care

CPT 2009 revised the description of prolonged care involving inpatient services (99356-99357). Whereas former descriptions depicted prolonged care time as direct, face-to-face time between the physician and the patient, the 2009 description states that these inpatient prolonged care codes could be used to report the total duration of unit time spent by a physician on a given date providing prolonged services to a patient.8

This means that the physician does not have to be at bedside for the entire duration of prolonged care.

To date, prolonged care for Medicare patients presents an issue. CMS has not changed the prolonged care definition in the Claims Processing Manual and, therefore, has not recognized this CPT revision. CMS maintains physicians can count only the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical time of the visit code billed.

Time spent reviewing charts or discussion of a patient with house staff and not with direct face-to-face contact with the patient, or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities, cannot be billed as prolonged services.8

Further clarification by local Medicare contractors is published on an individual basis. Ask your payors to determine the correct descriptor for counting prolonged care time.—CP

FAQ

Q: How many times does a hospitalist have to see a patient to report the “same day admit/discharge” codes?

A: Observation or inpatient care services, including admission and discharge services, are reported with CPT 99234-99236. Because these codes involve increased physician work (2.56-4.26 physician work RVUs) and a corresponding increase in reimbursement ($127-$207), the physician must personally perform each component of the service: the admission and the discharge. Medicare rules state: “The physician shall satisfy the E/M documentation guidelines for both the admission to and discharge from inpatient observation or hospital care, and personally document the type of stay (hospital treatment or observation care), the duration of the stay (>8 hours on one calendar day), and physician involvement.”7

It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.

Shared/Split Services

Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).

The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.

In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3

Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4

Teaching Physician Services

A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.

The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

  1. Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
  2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
  3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
  4. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
  5. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
  6. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
  7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
  8. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.

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