12 Things Hospitalists Need to Know About Billing and Coding
Documentation, CPT codes, modifiers—it’s not glamorous, but it’s an integral part of a 21st-century physician’s job description. The Hospitalist queried more than a handful of billing and coding experts about the advice they would dispense to clinicians navigating the reimbursement maze.
“Physicians often do more than what is reflected in the documentation,” says Barb Pierce, CCS-P, ACS-EM, a national coding consultant based in West Des Moines, Iowa, and CODE-H faculty. “They can’t always bill for everything they do, but they certainly can document and code to obtain the appropriate levels of service.”
Meanwhile, hospitalists have to be careful they aren’t excessive in their billing practices. “The name of the game isn’t just to bill higher,” Pierce adds, “but to make sure that your documentation supports the service being billed, and Medicare is watching. They’re doing a lot of focused audits.”
Some hospitalists might opt for a lower level of service, suspecting they’re less likely to be audited. Other hospitalists might seek reimbursement for more of their time and efforts.
“You have both ends of the spectrum,” says Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education for AAPC, formerly known as the American Academy of Professional Coders. “There are a lot of factors that would go into why a provider would code something incorrectly.”
Here’s how to land somewhere in the middle.
1 Be thorough in documenting the initial hospital visit.
When selecting the level of service for an initial hospital visit, the documentation consists of three key components: history, physical examination, and medical decision-making. The history includes the chief complaint as well as the review of systems. This is “an inventory of the patient’s organ systems.” Both the complaint and the systems review are often incorporated in the history of present illness, says Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist in the Department of Medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
A patient’s family history is commonly overlooked in a hospitalist’s notes, primarily when they know the patient from previous admissions for chronic diseases and when the family history will likely not have an impact on treatment. “If they do not document a complete review of systems or miss one of the histories, the service will definitely be down-coded,” Mulholland says, “no matter how complete the exam and medical decision-making documentation.”
2 Familiarize yourself with Medicare reimbursement rules in the state where you practice.
In some states, Medicare contractors require providers to document the status of each organ system reviewed individually. In other states, it’s acceptable to document a system review with pertinent findings, “whether positive or negative,” and the statement of “all other systems negative,” Mulholland says.
The auditor will give credit for the review based on the number of organ systems documented. “If you miss one system review, it will take down what otherwise would be a Level Three hospital admission to a Level One,” she says. “So there would be a significant financial impact.”
Medicare reimbursement for a Level Three initial visit in Mulholland’s area of practice—Philadelphia County in Pennsylvania—is $206.57, compared with $104.69 for a Level One. During this visit, each of the key components—history, exam, and medical decision-making—need to be documented completely for the provider to receive the highest level of reimbursement.
3 Ask about a patient’s social history.
Social history can be obtained by querying the patient about smoking, drug and alcohol use, his or her occupation, marital status, and type of living arrangement.
“Knowing the social history helps the hospitalist understand the home situation or social circumstances that may have contributed to the hospitalization or may complicate the discharge plan,” Mulholland says.
