Medical Billing Protocol for Discharge Summary Preparation, Signoff


Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

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