Patient care provided in the acute setting might not always end with discharge to the patient’s home. Frequently, a hospitalist will transfer the patient to a different unit in the hospital or an off-site facility to receive additional services before returning to their home. When the patient’s condition requires a transfer to a physical medicine and rehabilitation (PM&R) unit, a psychiatric unit, a long-term acute-care facility, or a skilled nursing facility, it is important for the hospitalist to identify their role, if any, in the new area of care. Physician billing will depend on several factors:
- A shared medical record;
- The attending of record in each setting; and
- The care rendered by the hospitalist in each setting.
A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for a 68-year-old male with hypertension and diabetes who sustained a hip fracture. The care plan includes post-discharge therapy and rehabilitation. When the hospitalist transfers care to a PM&R unit within the same facility for which the hospitalist is no longer the attending of record, they might be asked to provide ongoing care for the patient’s medical conditions (e.g., diabetes and hypertension). The hospitalist’s knee-jerk reaction is to bill for an inpatient consultation for the initial service provided in the transferred setting. This would only be appropriate if the request for opinion or advice involved an unrelated, new condition, and the requesting physician’s intent is for opinion or advice on how to manage the patient and not the a priori intent for the hospitalist to assume the patient’s medical care.
If consultation requirements are met (see “Consulataion Reminder,” p. 20), the hospitalist can report an inpatient consultation code (99251-99255). However, when circumstances do not fully represent the intent or need for consultative services but rather a continuity of the medical care provided during the acute phase of the hospitalization, report the most appropriate subsequent hospital care code (99231-99233) for the initial rehab visit and all follow-up services.
On occasion, the hospitalist will be asked to perform and provide the history and physical (H&P) for the patient’s “sub-acute” phase of care, even though the hospitalist is not the attending of record. This usually happens when the attending of record cannot complete the medical requirements of the H&P, either at all or as comprehensively as the hospitalist. When this occurs, the hospitalist should not report an initial hospital care code (99221-99223) because they are not the attending of record—the physician who admits the patient and is responsible for the patient’s stay in the transferred location.
Additionally, a consultation service (99251-99255) should not be reported, because the request involves the completion of a facility-mandated form and not an opinion or advice on caring for the patient. If medical issues require the hospitalist’s evaluation and management, there is medical necessity for capturing the hospitalist’s participation as subsequent hospital care (99231-99233). If no medical conditions present for the hospitalist to manage, the service will not be considered “medically necessary” by the payor.
Hospitalist groups provide patient care and coverage in a variety of facilities. Confusion often arises when the attending of record during acute care and the sub-acute setting are different hospitalists from the same HM group. The hospitalist who receives the patient in the transfer facility may err on the side of caution and report subsequent hospital care (99231-99233) because the group has provided ongoing patient care. In this scenario, the hospitalist group might lose revenue if an admission service (99221-99223) was not reported.
Day of Transfer Billing
A single hospitalist or two hospitalists from the same group might bill both the hospital discharge management code (99238-99239) and an initial hospital care code (99221-99223) when the discharge and admission do not occur on the same day if the transfer is between:
- Different hospitals;
- Different facilities under common ownership that do not have merged records;* or
- Between the acute-care hospital and a prospective payment system (PPS)-exempt unit within the same hospital when there are no merged records.
In all other transfer circumstances that do not meet the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.1 Of note, Medicare Part A covers inpatient care in psychiatric, rehabilitation, critical access, and long-term-care hospitals. Each of these specialty hospitals is exempt from the PPS established for acute-care hospitals in 1983.2 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
*Editor’s note: “Merged record” is not equivalent to commonly accessible charts via an electronic health record system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 220.127.116.11E. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
- Department of Health and Human Services. Office of Inspector General: Oversight of Medicare PPS-Exempt Hospital Services. HHS Web site. Available at: www.oig.hhs.gov/oei/reports/oei-12-02-00170.pdf. Accessed June 1, 2009.
- CMS. Medicare Claims Processing Manual: Chapter 12, Section 18.104.22.168H. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.