Section 6: Billing, Coding, and Clinical Documentation

INTRODUCTION

The medical record of an individual patient serves numerous functions. Ideally, the record should provide a comprehensive historical vehicle promoting excellence in care delivery to a patient, transcending communication barriers, and facilitating care coordination among multiple disparate providers and facilities (such as hospitals). However, the medical record also serves as the basis for a variety of financial, legal, and administrative functions including the documentation for both professional and facility fee reimbursement, quality and safety assessments (including pay for performance), malpractice litigation and disability determinations, and community-based care and public health initiatives.

Currently, the medical record of an individual patient is fragmented, with various pieces shared only sometimes among numerous providers. Hospitalists typically provide episodic, facility-based care. Fortunately, the proliferation, adoption, and increasing interoperability of electronic medical records (EMRs), and their evolution into personalized health records, still holds promise for consolidation and availability of all relevant clinical information to each provider participating in the care of a single patient.

SOME GENERAL PRINCIPLES

This chapter focuses upon the documentation requirements incumbent upon hospitalists for professional fee billing of their clinical services. Some general principles of clinical documentation warrant discussion despite this focus, and apply to both paper and EMRs.

The documentation of professional services should always comprise the essential components of a patient’s chief complaint, history, physical examination (PE), and medical decision making (MDM). The concerns of both patient and provider should be clearly recorded, including expectations (realistic or not) and satisfaction (and dissatisfaction). All diagnostic test orders and results should reside in the chart, as well as documentation of various specific services (eg, physical, occupational, speech, or rehabilitation therapy; home health services, durable medical equipment needs, and social work evaluations).

Corrections

At some point in time, every medical record requires a correction. In a paper document, draw a single line through the inaccurate portion and write a correction nearby, dating and signing the revision. The original entry thereby remains legible for future reference. For example, consider misidentification of a right swollen knee joint, when actually it is on the left: when the physician recognizes the mistaken documentation, the right side should have a single line drawn through it (ie, overstrike text appearing as ) and a note written nearby indicating that the left side is the accurate side. Sign and date these changes on the day of correction. Methods and appearances of corrections and amendments in EMRs continue to evolve, but all incorporate password-protected signatures with electronic date- and time-stamped entries.

Late-entry documentation

Like corrections, addenda or late entries can be made at any time and labeled as such, with a currently dated and timed signature. Also, explain why the entry was made late and not contemporaneously. For example, following a hospital visit, a hospitalist responds to a rapid response call and neglects to document the visit in the hospital medical record. When recognized the next day, document the hospital visit as a late entry and specify that the care was delivered the previous day.

AN OVERVIEW OF HOSPITAL INPATIENT PAYMENT SYSTEMS

As the most prominent payer in the United States, Medicare payment systems are of paramount importance to understand. Fortunately, Medicare policies are established by the Centers for Medicare and Medicaid Services (CMS) and available online through the CMS On-Line Manual System, so that everyone can in principle understand how claims are processed and payments are made. Medicare policies are largely consistent across the United States, and many private payers follow CMS’s lead. However, remember that regional Medicare Administrative Contractors develop local coverage determinations from CMS payment policy, and can create idiosyncratic interpretations of the documentation guidelines for evaluation and management (E/M) services. One such example would be the nuanced medical allowances for a detailed exam (see Physical Exam section) implemented by Novitas Solutions. Similarly, various third party payers have the right, as allowable under their contract with physician groups, to create unique documentation mandates and payment policies. Facilities also generate requirements, such as a required history and physical before a procedure, which do not comprise medically necessary, billable physician services.

Medicare pays hospitals for inpatient services using an inpatient prospective payment system (IPPS), which relies primarily on the diagnosis in order to group the services delivered to an inpatient into a Medicare severity-adjusted diagnosis related group (MS-DRG). Many diagnostic categories have two or three severity levels, differentiated by the presence or absence of a specified set of complications and comorbidities (CCs) or major complications and comorbidities (MCCs). Hospitals and other facilities frequently request hospitalists to clarify, expand, or specify their clinical documentation to ensure the assignment of a hospitalization to the proper MS-DRG. This single MS-DRG payment covers all facility services during the inpatient stay. Many payers have adopted a similar mechanism of providing a single, fixed payment for an entire hospitalization, often referred to as a case rate.

Some non-Medicare payers still reimburse hospitals and facilities with a fixed payment for each day, commonly described as a per diem rate. The daily payment potentially varies depending upon the types of services provided to the patient (eg, intensive care versus skilled nursing care). Other payment models continue to emerge as a result of health care reform, including the evolution of accountable care organizations and the proliferation of patient-centered medical homes.

AN OVERVIEW OF PHYSICIAN PAYMENT SYSTEMS

Physician services are typically reported using the American Medical Association (AMA) Current Procedural Terminology (CPT), fourth edition, which lists descriptive terms and identifying codes to report medical services and procedures. CPT provides a uniform language to accurately describe all medical, surgical, and diagnostic services and procedures. Even physicians receiving capitated payments or participating in various advanced payment models still typically report CPT codes for their services.

Hospitalists predominantly report E/M codes (CPT 99201-99499), which for Medicare exceed $32 billion annually and account for more than 40% of the Medicare physician fee schedule allowed charges. Other bedside procedures and diagnostic testing, sometimes performed by hospitalists, are also found in CPT. In selecting the proper E/M code, the site and nature of service determine the visit category; and the key components of history, physical examination, and MDM determine the specific level of CPT code within a visit category.

Many payers are now adopting Medicare’s recognition and regulation of nurse practitioners and physician assistants as advanced practice providers, independently able to provide, document, and bill for E/M services. The number of advanced practice providers performing hospitalist services is rapidly increasing. Therefore, when we refer to providers throughout this chapter, we include both physicians and these qualified advanced practice providers functioning in an independent billing role.

THE KEY COMPONENTS OF PHYSICIAN E/M DOCUMENTATION

Selection of an E/M level focuses upon the content of the three key components: history, PE, and MDM. Time is considered a fourth key component, but only affects the E/M level when counseling and/or coordination of care dominate more than 50% of the physician’s total visit time (see below). When counseling and/or coordination of care involves less than 50% of the physician’s total visit time, time is only considered a contributory factor and does not determine the E/M level.

Two sets of documentation guidelines have been elaborated by Medicare and largely adopted by other payers. The earlier 1995 guidelines are the most widespread, and generally applicable to hospitalists along with most medical and surgical specialists. The later 1997 guidelines elaborate specialty-specific physical examinations, as well as clearly articulate detailed physical examination requirements lacking in the 1995 guidelines. An added variation also exists between the two guidelines in aspects of history. The 1995 guidelines will be described in detail throughout this section, and the 1997 guidelines are highlighted below in a separate section for completeness.

HISTORY

The elements of history include the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and the past, family, and social histories (PFSHs). A chart note may not segregate these elements into unique subtitled areas, but rather the information may be interspersed amid the written, typed, or even dictated narrative.

Chief complaint (CC)

Typically, the reason for the visit is often quoted from the patient’s own words as a sign or symptom, such as, “my belly hurts.” Always document a CC in the progress note, even absent an acute complaint, such as, “pneumonia follow-up.” Avoid statements lacking a specific clinical reference (eg, “post-op visit Day #3”).

History of present illness (HPI)

The HPI conveys information about the CC, from either the origin (at an initial encounter) or the interval between sequential patient encounters. This information is arbitrarily allocated into eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms. The HPI is then quantified as brief (one to three elements) or extended (four or more elements). For example, consider this extended HPI: “Patient complains of increased (severity) pedal (location) edema that began 2 days ago (duration). Less able to walk. No chest pain (associated signs/symptoms).”

Review of systems (ROS)

The ROS refers to signs or symptoms experienced in conjunction with the CC. Fourteen systems are recognized: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (which includes the breast), neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic. Medical necessity, as deemed by the treating provider in light of the patient’s current or previous conditions, determines the number of systems required for review.

A ROS may be problem pertinent, extended, or complete. A problem-pertinent ROS documents one system directly related to the CC. An extended ROS requires documentation of two to nine systems, that is, the system that is directly related to the CC, along with one or more additional systems. A complete ROS documents 10 or more individual systems. When obtaining a complete ROS, to decrease the amount of time spent listing each system individually, both the 1995 and 1997 (see below) E/M documentation guidelines allow the physician to comment on the positive and pertinent negative systems, with an additional comment that the “remainder is negative.” However, insurers may not accept alternative phrases, and Medicare (and some non-Medicare) contractors seek individual documentation of each system when less than 14 systems are reviewed.

Past, family, and social histories (PFSHs)

The past history includes documentation of previous illnesses, hospitalizations, surgeries, medications, allergies, and immunizations. The family history provides information regarding potential hereditary illnesses. The social history may list details of the patient’s substance use (tobacco/alcohol/illicit drugs), sexual history, employment status, level of education, marital status, or living arrangements.

A pertinent PFSH includes a comment in any one of the three histories (ie, past, family, or social). Full credit for a complete PFSH requires a comment in each history (ie, past, family, and social) when reporting initial hospital, observation, or nursing facility care, consultations, and new office, home, and domiciliary visits. In contradistinction, emergency department (ED) services or established patient visits in the home, domiciliary, office, or other outpatient area require one comment in two of the three histories for credit as a complete PFSH.

Providers may review and comment that the “family history is noncontributory” and still receive credit for the family history from some insurers. Certain Medicare contractors, such as Palmetto GBA, prohibit this terminology and require specific documentation regardless of clinical relevance (eg, “family history negative for liver disease”). Also note that with subsequent services, both for hospital care and nursing facility visits, only an “interval history” is required and redocumentation of the PFSH is unnecessary from a billing perspective.

Determination of history level

The number of historical elements present in the chart note determines the level of history (Table 27-1). If all of the requirements are not met for a given level of history, select the level associated with the deficient element. For example, a comprehensive history requires documentation of the CC, ≥4 HPI elements, ≥10 ROS, and a complete PFSH. If the ROS only includes documentation for nine systems, a comprehensive history cannot be selected; report a service that requires only a detailed history: CC, ≥4 HPI elements, 2-9 ROS, and a pertinent PFSH.

Other circumstances

A PFSH obtained during an earlier encounter does not need to be rerecorded if the provider documents review and updating of the previous information. Update the history by describing any new information or noting the absence of change, along with the date and location of the earlier PFSH; this earlier PFSH must be contained in a printable area of the medical record. CPT requires only an interval history for subsequent hospital or subsequent nursing facility visits, and it is usually unnecessary to record information about the PFSH, which is unlikely to change in these settings.

Most auditors disallow a single statement as both an HPI element and ROS element. The ROS and/or PFSH may be recorded by ancillary staff, or on a form completed by the patient. The provider must document review and confirmation of this information recorded by others, either by a reference to the history form in the progress note or by initialing and dating the form, making any necessary annotations, additions, or corrections.

If unable to obtain history from the patient, the record should describe the patient’s condition or the circumstance that precludes obtaining a history, and what attempts the provider made to obtain the information. For example, “… patient sedated and paralyzed, unable to obtain additional history. Family currently unavailable to contact; information obtained from the staff and available medical records.” However, reviewers expect providers to incorporate historic information to the extent possible, from all reasonably available sources (eg, old records, emergency medical services documents, other provider documentation, or conversations).

Finally, although the physician may collect all of the information required for a complete ROS, the most common underdocumentation error is failure to document at least 10 systems. The second most common mistake is a missing family history or social history.

PHYSICAL EXAMINATION (PE)

Individual PE elements will be assigned to body areas (head and face, neck, chest, abdomen, genitalia/groin/buttocks, back/spine, and each extremity) or organ systems (constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, and hematologic/lymphatic/immunologic). Providers may document specific findings (eg, “abdomen soft”) or make a generalized comment (eg, “HEENT normal”). Abnormal findings must be specifically documented, such as “S₃”; however, a comment indicating “abnormal” without elaboration is insufficient.

The PE documented in the medical record is categorized as problem-focused, expanded problem-focused, detailed, or comprehensive. One comment in one area constitutes a problem-focused exam. The distinction between the expanded problem-focused and detailed examination under the 1995 Guidelines is the greatest ambiguity in physical examination documentation. Both the expanded problem-focused and detailed exams require documentation of two to seven systems. However, “detailed” is defined as an extended examination of the affected body area or organ system, in addition to other symptomatic or related organ systems. The number of required comments regarding the affected body area or organ system to consider the examination detailed has never been defined by either CPT or Medicare. Attempting to decrease ambiguity and variability among auditors, Novitas Solutions scores a detailed exam using the “4 × 4” rule: four elements examined in four body areas or four organ systems (totaling 16 documentation elements). In contrast, other contractors suggest using the 1997 guidelines (discussed later) for detailed exam requirements.

The comprehensive examination is a general multisystem examination or a complete examination of a single organ system. Medicare requires the minimum documentation for the general multisystem examination to include one comment in each of eight systems; of course, additional comments in each system and more than eight systems may be described, as clinically indicated. For example, a comprehensive examination may be documented as follows: “P = 76, BP = 120/80, RR = 12 (constitutional); HEENT normal (eyes and ENMT); neck supple (musculoskeletal); regular rate and rhythm (cardiovascular); lungs clear (respiratory); normal bowel sounds (gastrointestinal); no rashes (integumentary), normal gait (neurological).” The requirements for a comprehensive single organ system still remain undefined for use with these 1995 guidelines.

MEDICAL DECISION MAKING (MDM)

The complexity of MDM drives selection of a level of service. MDM is categorized as straightforward, low, moderate, or high. Three categories must be considered to determine the level of MDM complexity: the number of diagnoses, the amount and complexity of data, and the risk to the patient.

Number of diagnoses considered

This first category identifies the number of diagnoses and/or management options considered in the encounter, based upon the documentation. Up to four points are assigned to each problem, with more points assigned for new problems than for established problems, and a new problem requiring additional workup (ie, diagnostic testing) given the maximum four points. Established problems identified as worsening receive a higher value than stable or improving problems. A self-limited or minor problem (eg, sunburn) receives minimal credit as these issues typically do not warrant a defined plan of care (Table 27-2).

New problems require initiation of a care plan, while established problems may require modification or continuation of a care plan. An established problem has been previously considered by the physician or provider group (to allow for cross coverage and handoffs between same specialty providers in the same group) in the strictest of interpretations of the guidelines. Note that credit is also given for a problem considered, although not primarily under treatment by the physician. For example, in a patient receiving steroids for an inflammatory disease, the hospitalist receives credit for noting the potential adverse consequence upon serum lipids, even if a cardiologist is primarily treating the dyslipidemia. Notice, a chronic condition such as diabetes, cared for by an endocrinologist, is categorized as a new problem to the hospitalist newly treating the patient during an admission for ketoacidosis.

Established patients may also have new problems. For example, an asthmatic with a resolving flare may experience heartburn. This additional new complaint of heartburn may be considered new if commented upon in the progress note and no prior care plan by the hospitalist team for gastroesophageal reflux exists.

Physicians receive credit only for issues considered in the care plan. Diagnoses merely listed in the assessment and plan without elaboration of the care, or simply ascribing the care to others (eg, “diabetes—per endocrinologist”) are considered part of the patient’s problem list in the PFSH and do not add to the complexity of MDM. Additionally, new hospitalizations warrant new care plan development, and physicians can receive new problem credit even if the patient has been previously hospitalized by the same group. This is a nuance of inpatient and observation care only.

Data considered

The second category of determining the MDM complexity is the amount and/or complexity of data reviewed or ordered by the provider during the patient encounter. Both the type and source of information considered are valued (Table 27-3).

Ordering and/or reviewing of pathology/laboratory, radiology, and medicine data each provide separate but equal credit. Irrespective of the test volume in each category, only one point is allocated per category (ie, pathology/laboratory, radiology, or medicine) for the encounter. For example, the provider ordering a dozen serologic collagen vascular studies in the morning may also review the three results received in the afternoon; nonetheless, only one point is granted for this care. A single, separate point may be assigned each to pathology/laboratory, radiology, and medicine data, respectively, are cumulative in nature, and the chart note should refer to all the data reviewed or ordered to capture all of the provider work. In other words, if the chart note comments upon a radiology result (one point) and an echocardiogram order (one point), two points may be awarded for the amount of data in that encounter. Independently visualizing images, tracings, or specimens is considered separately, and additional to reviewing the formal interpretation, as long as the chart note clearly documents this occurrence (ie, “…my review of the EKG tracings showed…”). Without such specific reference distinguishing personal review of the images and of the formal interpretation, an auditor only provides minimal credit for merely reviewing the report. A reference to data review without a comment about the result (eg, “CXR reviewed…”) will yield no credit; therefore, be sure to include a comment on the findings (eg, “CXR reveals cardiomegaly…”).

Providers also receive credit for the additional effort of obtaining historical information from sources other than the patient, such as records from previous encounters or hospitalizations, and conversations with other health care professionals or family members. The chart note should specifically mention the source, along with the information reviewed (eg, “…spouse confirms loud snoring”).

Risk to the patient

The third MDM category assesses the patient’s risk of complications, morbidity, or mortality, with respect to the presenting problem, diagnostic procedures ordered, or management options chosen. Four levels of patient risk exist (minimal, low, moderate, and high), with examples of each risk type included in Medicare’s “Table of Risk” (Table 27-4). The limited number of examples serves as an illustrative reference for common clinical scenarios, but not as a comprehensive list.

When determining the level of risk, consider comorbidities as well as the plan of care in assessing a patient’s risk, thereby potentially increasing the complexity of MDM. Similarly, diagnostic studies or alternatively, procedures under consideration or excluded based upon excessive risk, impact the complexity of MDM (eg, “…will defer MRI, as potential morbidity of transport to magnet exceeds risks of empiric treatment”). Although many bulleted items on the table may pertain to a particular chart note, the single bulleted item in any risk category associated with the highest risk determines the patient’s risk level. For example, a note documenting the monitoring of liver function tests for potential hepatotoxicity, or blood counts for possible cytopenias, comprises high risk (drug therapy requiring frequent monitoring for toxicity). However, remember risk does not equal complexity: risk is but one category (among three) of MDM and not the sole contributor to complexity.

Assigning MDM complexity

Based upon the chart note, points are assigned for diagnoses managed and data considered, and patient risk is assessed. The final result of MDM complexity hinges on the two highest valued categories. In other words, two of the three categories must meet or exceed the requirements assigned to a specific level of complexity to select that level, as illustrated in Table 27-5.

To illustrate the assignment of MDM complexity, consider the following example. The chart note considers three stable established diagnoses (three points), several blood tests (one point), and high patient risk. The lowest of the three categories (data considered) is eliminated, and the lower of the two remaining categories (number of diagnoses) determines the moderate MDM complexity for the note. While most contractors utilize standardized concepts when assigning points, beware of contractors and other auditing programs who may impose different standards.

1997 GUIDELINES

Medicare issued a second set of revised documentation guidelines for E/M services in 1997. MDM and the level categories remained unchanged from the prior 1995 documentation guidelines, as detailed above. While ambiguity plagues many aspects of the 1995 guidelines, excessive proscription limits the 1997 guidelines. The 1997 guidelines made a single minor revision to the history, while the physical examination content received extensive modification. The requirements for each level of physical examination were heavily revised, and specialty-specific single organ system examinations defined. In response to widespread complaints from the physician community, CMS allowed physicians to document using either the 1995 or 1997 guidelines, according to their individual preference, and directed auditors to review the physician documentation based on the set of guidelines most favorable to the physician for the E/M code reported for the encounter. Most physicians, including hospitalists, find the 1995 guidelines most applicable.

History

The 1997 guidelines do not limit the provider to identifying individual factors associated with the CC (eg, duration, timing, and context). Rather, a provider may document the status of one or more chronic conditions; this option is most useful for subsequent hospital visits. A brief HPI documents one or two conditions, while an extended HPI documents a minimum of three conditions. Some reviewers allow this option only if applying the 1997 guidelines to the entire note. However, beginning with dates of service September 10, 2013, Medicare gives credit for the status of chronic conditions from the 1997 guideline and the physical examination from the 1995 guideline mixed within the same note.

Physical examination

The 1997 guidelines allow a provider to select either a general multisystem examination or any one of the single organ system examinations. Hospitalists typically utilize the general examination, which specifies examination elements to perform and document. Negative or normal comments remain acceptable for the 1997 guidelines, along with the mandate to specify comments on any abnormal findings. Documentation in the medical record of 1 to 5 specified (referred to as bulleted) physical examination elements comprises a problem-focused examination; 6 to 11 bulleted elements defines the expanded problem-focused examination; and a detailed examination requires 12 or more bulleted items.

For the 1997 comprehensive general multisystem examination (Tables 27-6 and 27-7), the provider must perform all the elements specified in at least nine organ systems or body areas but only needs to document a minimum of two elements from each of those nine systems or areas. For single organ system exams, all bullets must be performed; however all bullets in all shaded boxes and at least one bullet in each unshaded box must be documented.

DETERMINING LEVEL OF SERVICE

For both the 1995 and 1997 guidelines, assign a specific level to each of the three key components. Rate history and examination each as either problem-focused, expanded problem-focused, detailed, or comprehensive. Rate the complexity of MDM as either straightforward, low, moderate, or high. CPT correlates specific levels of the key components with certain levels of most E/M services.

Initial patient encounters (initial hospital care, CPT 99221-99223; initial and subsequent observation care, CPT 99218-99220 and 99234-6; consultations, CPT 99241-99245 and 99251-99255; and new office visits CPT 99201-5) require consideration of all three key components. Consider only two of the key components for subsequent hospital (CPT 99231-99233), observation visits (CPT 99224-99226), or established outpatient (CPT 99211-5). The lowest component of the two or three key components required determines the visit level. For example, a level three initial hospital service (CPT 99223) includes a comprehensive history, comprehensive exam, and high-complexity decision making (Table 27-8). If the documentation merely supports a detailed level of history, yet meets the requirements for a comprehensive examination and high-complexity decision making, report only a level one initial hospital service (CPT 99221). In contrast, if a subsequent hospital visit note contains a complete examination and high-complexity MDM, then report CPT 99233 and history need not even be considered (Table 27-9). When selecting visit levels for services that only consider two key components, MDM should be one of those two key components. While not stated in the documentation guidelines, medical necessity underlies every physician service and is most appropriately demonstrated through MDM. Reporting subsequent services with MDM as a key component thereby precludes the allegation of an unwarranted high-level subsequent encounter based upon merely a comprehensive, but medically unnecessary, history and examination for management of the presenting problem (eg, common cold).

TIME COUNSELING/COORDINATING CARE

CPT assigns most E/M codes a typical time to render a service, but importantly, the service duration need not last that length. For inpatient services, time accrues as unit or floor time in addition to face-to-face time. When more than 50% of the total service time involves counseling and/or coordination of care, the provider may select a code reflecting the total time spent with the patient, rather than the three key components. Time and the corresponding counseling details must be documented in the medical record when selecting the E/M code on the basis of time (eg, “25 of 35 minutes spent urging the patient to undergo a diagnostic biopsy”). Of course, record patient responses to counseling and all relevant history, examination, and MDM as necessary for good patient care. A subsequent hospital service involving 35 minutes spent by the provider permits selection of 99233 (Table 27-9).

TEMPLATED NOTES

Templated chart notes, whether formatted as preprinted paper progress notes with check boxes or electronically constructed as combinations of macros and click-boxes, are common, appropriate documentation tools. Such tools enhance legibility and facilitate efficient documentation in accord with the E/M guidelines. Unfortunately electronic notes often become the source for increasingly prevalent “cut-and-paste” errors, highlighting the need to balance efficiency with accuracy in providing safe, efficient care to complex patients. Make each note specific to the patient on that encounter date. Modify information and language brought forward from any previous encounters so the current documentation demonstrates the distinct clinical service of today. Do not include excessive data or repetitious information that is not relevant to the current service; such content is often misconstrued as being included merely to increase the billing level.

AUDIT TOOLS

Audit tools are useful adjuncts to ensuring adherence to E/M billing guidelines, patient safety and quality initiatives, and other process assessments. Such tools are often custom designed in the context of chart reviews and institutional initiatives, or implementing coding and billing audits associated with practice compliance plans. CMS has not developed or endorsed any formal audit tool for E/M services, although virtually all Medicare and non-Medicare contractors (eg, Novitas and First Coast Service Options, Inc) make their E/M score sheets available to assist providers in adhering to documentation guidelines.

SUGGESTED READINGS

CONSULTS

INTRODUCTION

Medicare stopped paying for the consult codes [99241-99245, 99251-99255] January 1, 2010. The consult codes paid more than their corresponding inpatient follow-up [99231-99233] and outpatient visit [99201-99215] alternatives, but came with very specific, but strict and confusing, situational and documentation criteria to allow for their reimbursement. Although Medicare stopped paying for the consult codes, they did not stop paying for consult services. The concept of needing the expertise of another provider is still essential to the practice of medicine. What has changed is how those services need to be reported for reimbursement to Medicare. Some private payors still reimburse for the consult codes, using the old Medicare situational and documentation guidelines, but these numbers are decreasing. Until 100% of insurers stop paying for the consult codes [99241-99255], two different payment systems for consults exist. Thus, the same work provided to two identical patients may be reimbursed differently depending on the patient’s insurer.

MEDICARE PATIENTS AND THOSE INSURERS FOLLOWING MEDICARE CONSULT RULES

The set of codes submitted for a consult to a Medicare patient is based on several variables: inpatient versus outpatient status, disposition after being seen in an emergency room (eventual admission vs observation status vs discharge home), and whether a patient is new or established to the physician specialty and billing group. (See Figure 28-1.)

INPATIENTS

Initial consults for patients in acute care hospitals and skilled nursing facilities (SNF) are billed with the same initial inpatient visit codes used for admissions [99221-99223 (initial inpatient visit), 99304-99306 (initial SNF visit)]. All subsequent consult visits are billed using the subsequent inpatient or SNF visit codes respectively [99231-99233, 99307-99310]. The final day seeing the patient as a consultant will still be billed using the subsequent inpatient and SNF codes, even if the consultant is contributing to or fully providing the patient’s discharge management. Only the admitting physician/billing group can bill for discharge management services [99238-99239]. Medicare will only pay for medically necessary visits and not just daily “routine” visits because the patient is still in the inpatient hospital or SNF.

If a new problem or question surfaces, or the consultant is reconsulted during the same inpatient admission, with or without a time lapse since the last consultant visit, a subsequent inpatient/SNF visit code [99231-99233, 99307-99310] would be submitted for this service.

If a consultant is asked to see a patient whom they provided a consult on during a previous admission, even with the same problem(s) as last admission, the consultant would still bill an initial inpatient/SNF visit code [99221-99223, 99304-99306] for this work.

In the event that the documentation for the initial consult does not meet the minimum documentation criteria for the lowest level of initial inpatient service [99221], Medicare will allow this work to be reported with subsequent inpatient visit codes [99231-99232]. The documentation criteria for these services parallels those of the lowest two levels of consult service for the old code set [99251-99252], which explains the rationale for this practice. Keep in mind that the ability to submit an initial consult service with a subsequent inpatient visit code does not hold true for admissions. For an initial inpatient visit (ie, admission) reported by the primary attending of record, if the documentation for this service does not meet the minimum criteria for the lowest level of service [99221], subsequent inpatient visit codes cannot be submitted for this work. This work would be reported with E/M code 99499 which means that the documentation for the service does not meet criteria for recognized E/M services. This would fall under manual review and be left up to the Medicare contractor to determine what if any payment would be given. Check with local Medicare intermediaries for deviation from this rule. At least one carrier, Noridian, as of the time of publication of this chapter, will allow use of subsequent inpatient visit codes [99231-99232] for this admission scenario.

Since more than one physician will now be submitting an initial inpatient/SNF code, the primary attending of record for the patient needs to attach modifier –AI (A “eye,” not A “one” or A “el”) to their initial inpatient/SNF service. Consultants should not use this modifier.

OUTPATIENTS

Occasionally, hospitalists are consulted on patients in an outpatient unit of the hospital, such as the ambulatory surgery center. Also, observation status patients are considered outpatients even though they may occupy a hospital bed in the same room as an inpatient. Initial consults for these patients are billed using outpatient visit codes [99201-99215]. Initial observation visit codes [99218-99220, 99234-99236] should not be submitted for this work. Within the outpatient set of codes are new patient [99201-99205] and established patient [99211-99215] codes. A consultant now needs to determine if a patient is “new” versus “established” to select the correct code set to use. A patient is considered “new” to an individual physician if they have not received any E/M services from any member of that physician’s billing group and specific (sub)specialty within the past 3 years, regardless of the location of the service. Note that billing for the professional component of a service, or writing an order on a patient does not affect the “new” or “established” status of a patient.

Below are some common examples to illustrate nuances with this definition.

1. An internal medicine consultant evaluates a Medicare observation patient on the neurology service. The consultant has never seen the patient before, but the patient was seen in the emergency room by an internal medicine partner in their billing group, moonlighting 2 years ago. This consult would be reported with an established outpatient code [99212-99215].

2. A hospitalist evaluates a patient in observation status at the request of the ENT service. This patient has a history of monthly admissions to the hospital medicine service for severe chronic obstructive lung disease (COPD) although not recently. The initial medicine consult would be billed using the new outpatient code set [99201-99205].

3. A patient, seen routinely by an endocrinologist in a multispecialty practice for years, is placed in observation status on the general surgery service with a consult request to an internal medicine hospitalist in the same multispecialty group as the endocrinologist. The patient has never been seen by the internal medicine group in the past. This consult would be reported with a new outpatient code [99201-99205].

4. A cardiologist read an electrocardiogram (ECG) on a patient last week and billed for the formal ECG report, but has never seen the patient before, and no one in their group has ever provided an E/M service to this patient. Subsequently, the cardiologist evaluates this patient who is being observed on the internal medicine service. The cardiologist would bill their initial consult using the new outpatient codes [99201-99205].

If a follow-up consultant visit is necessary, even on discharge day, all of these patients are now established patients, and this work would be billed using the established outpatient visit codes [99212-99215].

EMERGENCY DEPARTMENT PATIENTS

For consults on patients seen in the emergency department, the patient’s ultimate disposition will determine which set of codes to use to bill for the consult.

• Admission to an inpatient service. Only one CPT code will be submitted for an evaluation by a consultant in the emergency department, followed by admission to the inpatient service, an initial inpatient visit [99221-99223]. If that patient is admitted to a different subspecialty’s inpatient service, an initial inpatient visit code [99221-99223] is still reported for this work.

• Placement into observation status. If the above patient is eventually placed into observation status on the consultant’s service, only one CPT code will be submitted for both the work of the consult and the placement into observation, an initial observation visit code [99218-99220, 99234-99236]. If the patient is placed into observation status on a different subspecialty’s service, this work will now be reported with an outpatient visit code [99201-99215] based on whether they are “new” or “established” to the consultant’s billing group and subspecialty.

• Discharged home. Finally, if the emergency room patient is eventually discharged home, an emergency room visit code [99281-99285] will be submitted for the work of the consult.

PAYORS WHO STILL RECOGNIZE THE OLD CONSULT CODES

For individual state Medicaid programs and for private insurers, check with plan representatives to see if they follow the new Medicare rules, or if they still pay for the consult codes [99241-99255]. For those that still recognize consult codes, check with the individual payors as well as your compliance office to see if they follow the old Medicare consult situational and documentation guidelines or if they have their own internal set of requirements.

In order to bill for a consult based on the old Medicare guidelines, several criteria have to be met. The Mnemonic “The 3 R’s” refer to these criteria. The consult has to be REQUESTED by another provider who wants the consultant to RENDER their opinion about (a) specific question(s), and the ensuing recommendations must be REPORTed back in writing to the requesting provider. The essence of a consult in this system, is that another provider seeks the opinion of a consultant with expertise above and beyond his own for a particular problem or set of problems. The concept of a “REQUEST for opinion” is stressed for three reasons (1) to distinguish it from a self-referral by the patient, which cannot be reimbursed as a consult (2) to distinguish it from a transfer of care, and (3) to prevent improper payment for “protocol” care that may not have adequate medical necessity documented in the chart. For example, if a hospital mandates that 100% of patients admitted for surgery or to a psychiatry ward must have a medicine consult, this could lead to nonbillable work. In these situations, a preprinted admission form requesting a medicine consult per “hospital policy” without documented medical necessity for each individual patient situation, would lead to nonbillable work. If a 25-year-old healthy female is admitted to general surgery for complications after an elective cholecystectomy, but has no other medical issues, there is no medical necessity for a medicine consultant to see the patient. The surgeon does not consciously request this service or have a particular question for the medicine consultant to answer, and does not need the internist’s expertise to manage the postoperative issues. A hospital mandated task is therefore not reimbursable through the patient’s insurance.

Because the consult codes reimburse higher level per level, than their subsequent follow-up counterparts, there is a big push to ensure that an opinion was requested, and not a transfer of care. This is the essence of a consult for those insurers that still follow these guidelines. For example, medical consultation request for an opinion regarding selection of anti-hypertensive medication in a pregnant inpatient would meet criteria for allowing a consult [99251-99255] to be billed, even if the recommendations include continued concurrent care of the hypertension by the internist. On the other hand, if the obstetrician is not comfortable managing hypertension at all, and wants the care of that problem to be totally managed by the internist, the essence of the request for help is no longer for an “opinion” about management. The request is for the internal medicine consultant to take over the care of the hypertension while the obstetrician continues to manage the other aspects of the patient’s care is referred to as a “transfer of care.” If the patient remains on the obstetrician’s service and the internist provides concurrent care, managing hypertension, this work cannot be reported with the “transfer of the patient to another service” consult codes [99251-99255]. In this concurrent care situation, the internal medicine consultant would report this work with a subsequent inpatient visit code [99231-99233]. For those payors who do not follow the new Medicare rules, only one initial inpatient visit [99221-99223] can be reported and reimbursed per patient per admission, thus the reimbursement for this work is substantially lower than if it were reimbursed through the consult codes [99251-99255].

The final criterion of REPORTing recommendations speaks to good medical documentation. Although a consultant may opt to call the requesting physician with urgent recommendations for good quality patient care, these recommendations need to exist in writing, accessible by the requesting physician. In the inpatient setting, the consultant note entered into a shared medical record will satisfy this criterion.

INPATIENTS

Initial consult visits to inpatients in both acute care settings as well as SNFs are billed using inpatient consult codes [99251-99255]. All subsequent visits are billed using inpatient/SNF follow-up codes respectively [99231-99233, 99307-99310].

OUTPATIENTS

Consults to patients seen in an outpatient area of the hospital, including observation status patients, are billed with the outpatient consult codes [99241-99245]. If a follow-up consultation visit is needed, it would be billed using the established outpatient visit codes [99212-99215]. Check with individual state Medicaid programs and private payors to see if they require the subsequent observation visit codes [99224-99226] instead, for observation status patients.

EMERGENCY DEPARTMENT PATIENTS

Just as for Medicare patients, the physical location of the patient is not what determines the selection of codes to use for billing consults. It is the patient’s “status.”

• Admission to an inpatient service. For patients located in the emergency department who have already been admitted to an inpatient service, use the inpatient consult codes [99251-99255]. If the consultant admits the patient to their inpatient service on the same date as the consult, only one CPT code for the work of both the consult and the admission should be submitted—an initial inpatient admission code [99221-99223].

• Observation status. If the patient in the emergency department is assigned observation status on a different service from the consultant’s, the consult will be billed using the outpatient consult codes [99241-99245]. If the consultant places the patient into observation status on his own service on the same calendar date, only one CPT code should be submitted for all of this work—an initial observation visit [99218-99220, 99234-99236].

• Discharge to home. If the patient is only under the care of an emergency room physician, and is eventually discharged home, report this work with outpatient consult codes [99241-99245].

CRITICAL ILLNESS

If the patient is critically ill during the initial consult visit and >30 minutes of critical care is provided by the consultant, only critical care [99291, 99292] and no other consult code set would be reported for that day. In the event that a consult is completed and at a later time on that calendar date, the consultant provides >30 minutes of critical care to the patient, both the consult and critical care service can be paid. The consult work would be reported using the rules above to select the appropriate code set.

SPLIT/SHARED VISITS

Although previous guidance from Medicare has stated that a consult cannot be provided as a split/shared service, those rules only applied to consults reported with CPT codes 99241-99255. With Medicare consults now reported using different code sets, the rules for split/shared visits for Medicare patients now default to the rules for whichever set of codes are being reported for the consult. Thus, for inpatient consults reported with initial inpatient visit codes [99221-99223], these services can be provided and billed as split/shared visits. Check with individual nonmedicare payors for their rules regarding this situation.

COMANAGEMENT

The terms “comanagement” and “concurrent care” are often used interchangeably. Concurrent care is the situation when two physicians are managing different aspects of the patient’s care on the same calendar date on a more extensive basis than a one-time consultation, usually discussed in reference to two physicians submitting claims for inpatient follow-up services [99231-99233]. Two initial inpatient services [99221-99223] submitted on the same calendar date will be interpreted as consultation care and not fall under this discussion. The Medicare manual clearly states that the work of both physicians is reimbursable as long as the documentation reflects the medical necessity for each physician to provide their service. Although the two physicians are usually from different subspecialties, in the event that both are from the same specialty but one has documented expertise above and beyond the other, both services may be paid. An example of this could be an internal medicine hospitalist who is managing a patient with a COPD exacerbation, but elicits the help of another internal medicine hospitalist with expertise in pain management, to take over the daily care of the patient’s severe refractory chest pain from lung cancer. The medical necessity of each physician’s care should not only be reflected in the medical record, but also by each claim being submitted with different ICD-10 codes, showing the different aspects of care each provider is managing on that particular date. If both providers submit their service with the same primary ICD-10 code, only the first claim received by Medicare will be reimbursed. The second one will be denied.

Comanagement, defined by the Society of Hospital Medicine (SHM) and its Advisory Panel, is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” By convention, this term is used when a more formal arrangement is made between two physicians providing concurrent care. In the common situation involving a surgeon and medicine provider, the surgeon manages surgery related issues and the medicine hospitalist manages the patient’s medical conditions on an ongoing basis, often for the entire duration of the admission, and usually with the formal arrangement outlining each specialty’s responsibilities. From the start, the patient will be admitted to one service, with an order for the other subspecialty physician to see the patient. Just as in the example in the consult section above, the documentation must support the medical necessity for the second physician to be involved, not just for the initial visit, but also for each daily visit. Situations will arise where each physician in a comanagement arrangement may not need to see the patient every single day of the admission. No billing should be submitted for these days, even if the patient is physically seen by the physician, based on a mandated hospital protocol. Without documented medical necessity, this work is not reimbursable.

TIME-BASED BILLING

Several E/M services can be billed based on time (Table 28-1), with different billing nuances for each code set. In certain situations, the rules allowing reimbursement for these services differ between the CPT and Medicare manuals. When billing based on time, the only time that can be counted toward reimbursement of a service, is the billing provider’s time, not time spent on patient care by the resident, student, social worker, or nursing staff. For hospital based services, in addition to face-to-face time, the majority of E/M services also allow inclusion of time spent by the provider on the patient’s floor or in their unit (“unit/floor time”) providing patient care, toward billable time. In general, time is added up from 12:01 am to 11:59 pm, not over a 24-hour period, and does not need to be continuous. One exception to this is in the event that a time-based service is started before midnight, continuously provided, but not completed until after midnight. The CPT handbook advises if this should occur, to add up time that the service was provided continuously, and to bill for it on the date the service began.

COUNSELING AND COORDINATION OF CARE

When counseling and/or coordinating care (CCC) is the dominant feature of certain E/M visits, that is, when more than 50% of the total visit time (face to face and/or unit/floor), is spent counseling the patient and or coordinating their care, the level of service provided may be determined by the total visit time rather than by quantification of the documented history, physical, and medical decision making (MDM). The typical total visit times associated with these services are shown below.

For example, if a patient is seen for inpatient follow up of a pulmonary embolism (PE) and a compliant level 2 [99232] visit is documented based on history, physical, and MDM, but it is also documented that >50% of a 35-minute face-to-face visit is spent counseling the patient on risk factors for a PE, evaluation, and treatment, time is now the controlling factor and a level 3 [99233] visit can be billed even though the history, physical, and MDM only amount to a level 2. Medicare will only allow time-based billing for CCC for inpatient admissions and follow-ups [99221-99233], SNF admissions and follow-ups [99304-99318], new outpatient visits [99201-99205], established outpatient visits [99212-99215], and other home services [99324-99350]. Medicaid and other insurers who follow the CPT handbook may also allow time-based billing for CCC for observation services [99218-99236] and consults [99241-99255] as well.

The Medicare Claims Processing Manual Chapter 12 states that the amount of CCC time may be estimated. In addition, the CPT manual instructs the provider to round the total visit time to the closest “average” total visit time. Thus in the example above, if 32 minutes were spent with the patient, 32 is closer to 35 minutes (average visit time for a level 3 follow-up [99233]) than it is to 25 minutes (average visit time for a level 2 follow-up [ 99232]), and a level 3 service would be billed. This differs from the rules governing prolonged service total time determination below.

Tasks that count toward counseling the patient include but are not limited to discussions of the plan, evaluation, procedures, prognosis, treatment options, risk factor reduction, and patient and family education.

In order to bill for these services, two different amounts of time must be documented: the total visit time, and the portion of that total visit time that was spent CCC. Check with insurers and local compliance offices to see if the term “>50% of the total visit time was spent counseling the patient” is acceptable or if the specific number of minutes spent CCC needs to be explicitly documented. Neither the Medicare manual nor the CPT handbook list this as a documentation requirement. The most common documentation pitfall in successfully getting reimbursed for CCC time, is reporting only one time amount, thus making it impossible to determine that >50% of the total visit time was spent CCC. In addition, lack of a brief description of what was discussed during that time will cause a denial; the medical necessity for investing that time into the visit may not be obvious.

Examples of minimally acceptable reporting of time for billing the visit based on CCC:

1. I spent 20 minutes out of a 25-minute visit face-to-face and unit/floor time, counseling the patient on the safe use of home oxygen, and coordinating care with social work, setting up home oxygen, home nursing, and pulmonary rehab (level 2 inpatient follow-up visit [99232]).

2. I spent 35 minutes face to face with the patient today. Twenty-five of those minutes were spent counseling the patient on her new diagnosis of breast cancer, the next steps in work-up, and possible treatment options including chemotherapy and XRT (level 3 inpatient follow-up visit [99233]).

3. I spent 75 minutes with Mr X face-to-face and unit/floor time. More than fifty percent of that time was spent counseling the patient. The patient has very low health literacy and needed extensive counseling regarding acute renal failure, necessary inpatient work-up, and possible need for dialysis (level 3 inpatient admission [99223]).

4. I spent 40 minutes face to face with the patient. One hundred percent of the time was spent counseling the patient on hospice and the grave prognosis for his metastatic lung cancer (level 3 inpatient follow-up visit [99233]).

Examples of unacceptable reporting of CCC time for billing:

1. I spent 25 minutes counseling the patient on new diagnosis of lung cancer.

2. I spent 15 minutes face to face with the patient discussing the hospital course for his pneumonia.

3. I spent 10 minutes out of a 30-minute visit counseling the patient on what CHF is, low salt diet, and decreased fluid intake (10 minutes is less than 50% of the total visit time). This visit cannot be billed based on time; the documentation of history, physical, and MDM would be used to determine the level of service. Specifically, even though 10 minutes is >50% of a level 1 inpatient follow-up average visit time (15 minutes), this statement cannot be used in lieu of documenting the history, physical, and MDM to bill for the service.

4. I spent today’s entire visit counseling the patient on the differential diagnosis of his diarrhea and the planned work-up. (An auditor cannot try to determine how much time you spent with the patient based on the time orders were written, or the note was entered in the EMR. This service cannot be billed based on time.)

PROLONGED SERVICES

Prolonged service codes [99354-99359] are add on codes used when more than 30 minutes of care is provided beyond the typical or average visit time for the E/M service. They can never be billed alone, without their companion code—the primary E/M service. Time can be added up over the course of the calendar date not only by the provider, but also by their covering partners, including involvement by a nocturnist; the time each provider spent over the calendar date can be aggregated to determine to level of service provided. In this situation, the prolonged service would be reported under the NPI of the provider who is billing for the primary E/M service. Relative value units (RVUs) between the two providers would need to be adjusted internally for productivity purposes. Both physicians and nonphysician providers (NPPs) can bill for prolonged services. Finally, prolonged services may be provided and billed for as a split/shared visit. No restrictions are identified in either the CPT or Medicare manuals on how much time the physician must spend on the service relative to the NPP, in order to bill a split/shared visit. The documentation must clearly reflect that each provider performed a substantive portion of the service.

There are several differences between Medicare and CPT manuals’ rules governing how and when prolonged services may be provided and how they must be documented. Medicare only allows prolonged services to be billed when the primary E/M visit is an inpatient admission or follow-up [99221-99233], SNF admission or follow-up [99304-99318], new outpatient visit [99201-99205], established outpatient visit [99212-99215], or home or domiciliary visit [99324-99350]. Medicare does not allow prolonged services to be billed with observation admissions and follow-ups [99218-99236], however, the CPT manual does allow prolonged service billing with these observation services as well as with the consults codes [99241-99255]. For all payors including Medicare, prolonged services can never be billed with discharge management services [99238-99239, 99217], critical care [99291-99292], or procedures. In general, the direct patient contact services 99356-99357 are added on to inpatient and observation services, and 99354-99355 are added on to outpatient services (Table 28-1). 99358-99359 are prolonged services without direct patient contact, that is, without a face to face, and are not reimbursed by Medicare. These codes are usually used when extensive time is spent in chart review. Payment for these services varies among private insurers.

99354, 99356, and 99358 are billed for the “first hour” of prolonged service provided. These services can be billed once 30 minutes of prolonged service has been provided; the rules governing prolonged service care allow for each unit of service to be billed once 50% of the service time in the description has been met. 99355, 99357, and 99359 are billed for each additional “half hour” of prolonged service after the first hour of prolonged care. These services cannot be billed unless 99354, 99356, or 99358 has already been billed with the primary E/M. Again, once half of the time in the description is met, that is, 15 minutes, these services can be billed. Thus, in the inpatient setting, if 105 minutes of prolonged service has been provided beyond the typical visit time for the primary E/M visit, the first hour of prolonged care may be billed, PLUS the next half hour of care, PLUS another half hour of care. In addition to the primary E/M service, 99356 and 99357 × 2 would be submitted in this example. No modifiers are needed for billing these services. Medicare requires the service to “meet or exceed” the threshold time to allow reimbursement for prolonged services (Table 28-1). Note that this is different from the instruction to “round” to the nearest average visit time when billing for CCC. Thus if a level 2 inpatient visit is performed (typical visit time 25 minutes) and 52 minutes of face-to-face care was provided, the 55-minute threshold needed to bill for the first hour of prolonged service [99356] has not been met, and the additional 27 minutes of care provided in this example is not reimbursable; only the level 2 inpatient follow-up [99232] would be submitted for this care. Table 28-2 shows the cut off times needed to bill each unit of prolonged service.

The rest of the discussion will focus only on services with direct patient contact [99354-99357]. Medicare only allows face-to-face time with the patient to be counted toward prolonged service billing, both in the outpatient as well as the inpatient setting [99354-99357]. Notice that this is different from Medicare’s rules for CCC, discharge management services, and critical care which all allow unit/floor time to be included as well. The CPT manual defines “direct patient contact” to mean only face-to-face time in the outpatient setting [99354-99355] but also time spent on the patient’s floor or in their unit for inpatient services [99356-99357]. This has a large impact on how prolonged services may be billed.

Prolonged services may be provided in addition to any level of service within the code sets above as long as >50% of the prolonged service time was not spent counseling the patient or coordinating their care. In the situation where CCC is the key feature of the visit, the highest level of service in the E/M code set must be used as the primary E/M before determining if any prolonged service time is billable. If less than 30 minutes of prolonged services are provided, that work is not separately reimbursable.

Example 1: A patient is seen with a new diagnosis of colon cancer and a fully compliant level 2 inpatient follow-up visit [99232] is documented, based on history, physical, and MDM. Seventy-five minutes of face-to-face plus unit/floor time care (total visit time) is provided to the patient. Only 60 minutes of that time was face-to-face time, and >50% of the total visit time was spent counseling the patient regarding the new diagnosis, further necessary testing, treatment options, and plans for consultants. Although only a level 2 visit is documented, since CCC is the key feature of the service, the visit can be billed based on time. The highest level of inpatient follow-up service is a level 3 [99233] which is associated with an average visit time of 35 minutes. In Medicare patients, only face-to-face time can be used when determining if prolonged service time is separately reimbursable. Only 60 minutes of the total visit time was face to face. This means that 25 minutes of prolonged service care was provided (60 minutes total face-to-face time minus 35 minutes typical visit time for a level 3 follow-up). In this scenario, those 25 minutes are not separately reimbursable. This service for a Medicare patient would be reported as a level 3 inpatient follow-up [99233].

Reimbursement would be different if this patient does not have Medicare, and the insurer follows the CPT manual. The total visit time would now be 75 minutes, adding in time spent providing care on the patient’s floor or in their unit. Now in addition to the level 3 inpatient follow-up visit, there are 40 minutes of prolonged service (75 minutes direct patient care time minus 35 minutes typical visit time for a level 3 inpatient follow-up). This service would now be reported as a level 3 inpatient follow-up [99233] PLUS the first hour of prolonged service [99356] which would result on average in ~$95 additional income.

Example 2: A non-English-speaking patient with an asthma exacerbation and lots of anxiety continues to call nursing several times during the day with shortness of breath, requiring repeated history taking, physical exam, and reassessment after each albuterol nebulizer treatment. In addition, each interaction with the patient requires the assistance of an interpreter. A compliant level 2 inpatient follow-up visit [99232] is documented. Sixty minutes of face-to-face care is provided intermittently over the course of the day. The typical visit time for 99232 is 25 minutes. Thirty-five minutes of prolonged service that is not dominated by counseling or coordination of care is best reflected by 99232 PLUS 99356.

For Medicare, start and stop times for prolonged services and the indication for the prolonged time need to be documented along with a brief summary of what was done during that time in addition to the total face-to-face time providing care on that calendar date. The CPT handbook does not include a requirement for documenting start and stop times to bill for this service. There may be variable requirements among state Medicaid and private payors.

CRITICAL CARE

Critical care is defined in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.12, as a physician’s direct delivery of medical care of a high-complexity MDM, to a critically ill or injured patient to prevent or stop imminent or active acute organ failure. A critical illness or injury acutely impairs one or more vital organ systems so that there is high probability of imminent or life threatening deterioration in the patient’s condition. Some examples of critical illness from the Medicare manual include circulatory failure, shock; renal, hepatic, or respiratory failure. Chronic organ failure management does not meet criteria for critical care services. Examples of this include chronic vent management and routine hemodialysis.

For a service to qualify as critical care, all four criteria must be met and adequately documented:

1. The medical necessity refers to a statement about the patient’s illness. The Medicare manual states “…The failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition….”

2. The service meets criteria for high-complexity medical decision making, and the high-complexity MDM is adequately documented in the chart.

3. The care is directly furnished by the physician, not by the resident, and not by a NPP in a split/shared situation. Critical care cannot be performed and billed as a split/shared visit.

4. The patient has a critical condition as defined above. Since critical care encompasses not only the “treatment of organ failure” but also the “prevention of further deterioration in the patient’s condition,” it is not a requirement that the person have an emergency or crisis situation to bill for critical care. The physician’s documented clinical judgment that the patient is at high risk of impending organ failure, or further deterioration in clinical condition, will support this criteria.

Seeing a critically ill patient does not automatically allow critical care billing. For example, an ophthalmologist seeing a septic patient on pressors, for glaucoma treatment, cannot bill for critical care.

There is no restriction to where critical care can be provided. It is not uncommon to provide critical care to a patient in a regular medical ward with an acute change in clinical status, while awaiting transfer to an intensive care unit. A patient is in the intensive care unit does not automatically allow for a critical care service to be billed. For example, a patient admitted to the ICU for acute respiratory failure 7 days ago, unable to wean off the ventilator, but stable for 3 days on their current vent settings, awaiting tracheostomy, no longer meets critical illness criteria. Neither does a patient who is in the ICU due to increased nursing needs such as a patient in diabetic ketoacidosis who needs glucose finger checks every hour, and the high nurse to patient ratio on the general ward, makes this level of care impossible or unsafe. Critical care billing is not warranted on a patient in an ICU bed only because the hospital policy requires it for their treatment, such as an insulin drip.

Critical care is a time-based service that follows the general rules of time-based coding. Both face-to-face and unit/floor time can be counted toward billable critical care time as long as the physician is in close proximity to the patient to immediately intervene for the minutes of reported critical care. If the physician is reviewing lab data on the patient’s floor but the patient is on a different floor getting a test done, in this scenario, the unit/floor time cannot be counted toward critical care time. For time reported as critical care time, the physician must provide their entire attention to management of the critically ill patient. For example, if the physician is at the critically ill patient’s bedside while an ECG is being performed, and while waiting, he is multitasking and looking up labs on another patient, this time cannot be counted toward critical care time. A minimum of 30 minutes of critical care must be provided to bill for critical care services. Twenty nine minutes or less of critical care would be billed with an E/M code that best reflects the service provided, such as an admission code [99221-99223] or inpatient follow-up code [99231-99233]. Once 30 minutes of critical care is provided, the first hour of critical care [99291] can be billed. Each additional half hour of critical care [99292] can be billed for thereafter (Table 28-3).

In addition to time spent face to face with the patient taking a history and performing a physical exam, other activities that count toward critical care time include the following:

1. Time spent reviewing test results while on the patient’s floor or in their unit, and does not fall into the pitfall situation above. Time spent personally viewing a chest x-ray in the radiology suite on a different floor or looking at a peripheral smear in the hematology lab cannot be counted toward critical care time.

2. Time spent discussing the care plan with nursing staff or other consultants.

3. Discussions with family members or surrogates when both of these criteria are met (a) the patient lacks capacity or unable to participate in their own care and (b) the discussion directly impacts decision making. These discussions will count toward critical care time even if they occur via phone on the patient’s floor or in their unit. However, time spent on routine updates to family cannot be counted toward critical care services, and is not separately reimbursable.

4. Time spent performing procedures that are bundled into critical care (Table 28-4).

Activities that cannot count toward billable critical care time include work that does not directly contribute to the patient’s care, even if performed at the patient’s bedside:

1. Time teaching

2. Time looking up literature

3. Family updates, even if at the request of the patient

4. Time performing separately reimbursed procedures

Certain procedures when performed on the same date as a critical care service and by the same provider, are bundled into the reimbursement for critical care and cannot be billed for separately. (Table 28-4). Any medically necessary procedure not included in this table can be billed separately from critical care, such as central line placement, cardiopulmonary resuscitation, and intubation to name a few. The documentation should clearly state that the time performing these unbundled procedures is not included in the reported critical care time.

When critical care is provided by the same physician/billing group on the same date that another E/M service such as an inpatient admission, follow-up, or consult was provided earlier in the day when the patient was not critically ill, both the earlier E/M and the critical care service can be reimbursed. The exception to this rule is when the other E/M service is an emergency room visit [99281-99285]. An emergency room service cannot be paid on the same date as a critical care service by the same physician/billing group.

In a coverage situation, such as a change in shifts where a partner in the same billing group continues to provide critical care on the same calendar date, critical care time can be aggregated as long as the initial physician provided at least 30 minutes of critical care. For example, if Dr A provides 40 minutes of critical care at 6 pm and then Dr B takes over and provides an additional 35 minutes of critical care at 7 pm, the critical care time can be aggregated. A total of 75 minutes of critical care was provided; the first hour of critical care [99291] would be submitted by Dr A and an additional half hour of critical care [99292] would be submitted by Dr B. However, if Dr A had only provided 25 minutes of critical care and Dr B provided 50 minutes, although they still provided a total of 75 minutes of critical care, Dr A did not provide at least 30 minutes before going off shift. They cannot aggregate their critical care time. Dr A would bill an appropriate E/M code that best represents their work such as an inpatient admission or follow-up, and Dr B would bill for the first hour of critical care [99291].

CONCURRENT CARE

Two different physicians from different specialties can both receive payment for critical care services on the same calendar date if there is medical necessity for each of them to provide this level of care; however, two physicians cannot get paid for the same exact same minutes of critical care. For example, if Dr A, an internal medicine hospitalist, provides 30 minutes of critical care from 9 to 10 am stabilizing a patient with impending respiratory failure, and Dr B, the intensive care physician, provides critical care between 10 and 11 am, each physician would submit a claim for the first hour of critical care [99291]. In the event that both physicians provide care at the same time, only one physician will get paid for critical care. The other physician should submit an E/M code that best represents their work.

Having different subspecialty designations does not automatically allow each physician to submit a claim for the first hour of critical care. In the event that a member cross covering a patient happens to have a different subspecialty designation, but their role is to continue the care started by the previous physician, the work of the two physicians would be aggregated. For example, in a hospital medicine group, if Dr A is an internist and provides critical care for 30 minutes and then their partner Dr B, a cardiologist, comes on to cover the night shift and provides an additional 30 minutes of critical care, even if the patient’s critical illness happened to be a cardiac problem, in this situation, the two physicians would aggregate their work. A total of 60 minutes of critical care was provided, which is only enough to bill for the first hour of critical care. Only 99291 can be submitted in this scenario.

When providing critical care in tandem with a resident, the only time that the physician can count toward critical care billing, is the time they personally provide critical care, or time they are physically present while the resident provides critical care. For documentation, the resident’s note can help support the high complexity of MDM. In addition to meeting all teaching physician (TP) presence and documentation criteria, and writing a valid attestation statement linking the TP’s note to the resident’s note, the TP must personally document the following to bill for critical care.

1. The patient was critically ill at the time the TP was physically present and provided the service.

2. What the critical illness is. ICD-10 codes for a critical illness must be used, or the claim will be at high risk of initial denial.

3. The nature of the treatment and management they personally provided.

4. The number of minutes of critical care that they personally provided.

Documentation of the above by the resident is insufficient for billing. An example from the Medicare manual of minimally acceptable TP documentation for critical care: “Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care.”

DISCHARGE MANAGEMENT SERVICES

Discharge management services can only be billed by the primary attending of record, or a partner covering that day. All other consultants should bill an inpatient follow-up visit [99231-99233] or an established outpatient visit [99212-99215] based on the patient’s inpatient versus observation status as well as payor rules for observation services. For inpatient discharge management, there are two levels of service: <30 minutes [99238] or >30 minutes [99239]. Both face-to-face and unit/floor time spent in discharge activities count, including but not limited to taking a history, the final physical exam, counseling the patient and family, reviewing data, writing prescriptions, and ordering follow-up appointments.

The only required documentation to bill for discharge management services is a statement attesting to having a face-to-face visit with the patient on the date of discharge management services. For legal, ethical, and high-quality patient care reasons, further documentation of the details of that visit would be prudent. When providing the higher level of inpatient discharge management [99239], documentation must explicitly state how much time was spent on discharge management as well as a brief summary of what was done during that time. Lack of this statement will prevent reimbursement for the higher level of care [99239]. No time amount needs to be documented when billing the lower level of care [99238]. If extensive amounts of time over 30 minutes are spent on discharge management, there is no additional reimbursement for this care. Prolonged services cannot be billed with any discharge management code. There is only one level of discharge management for observation services regardless of the amount of time spent on care.

One of the most common documentation errors preventing reimbursement for the higher level of inpatient discharge is the statement “I spent 30 minutes on discharge management.” As opposed to other time-based services where 30 minutes is the minimum amount needed to bill a unit of service (ie, prolonged service, critical care), more than 30 minutes must be spent in discharge management to allow reimbursement for the 99239. This author suggests documenting the actual amount of time spent, in minutes.

PALLIATIVE CARE

Although palliative care has had its own subspecialty designation (17) since October 2009, many internal medicine hospitalists (subspecialty 11) have developed expertise in this field without formally changing their subspecialty designation from 11 to 17. When functioning as a consultant providing concurrent care to patients under the care of a colleague in the same subspecialty, there are several “best practices” to be aware of to minimize claims denials.

SUBSPECIALTY DESIGNATION

When providing concurrent care, one of the first pieces of evidence that medical necessity exists for two physicians to manage a patient on the same calendar date, is different subspecialty designations. A physician can go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) at any time and change their primary and secondary subspecialty designations. The physician should have evidence of expertise in their primary subspecialty designation; this does not have to be completion of an accredited fellowship program in that field. Recognition at the local, regional, or national level of expertise via activities such as publications, public speaking engagements, or development of institutional protocols or curricula, would satisfy this criteria. Documentation of constant and updated Continued Medical Education (CME) credit in that field would also count. Many physicians list their primary subspecialty designation as the field that they provide >50% of their services in. For internal medicine palliative care hospitalists, the percent of services provided as an internist may often outweigh that of their palliative care services; symptom-driven ICD-10 coding, complete descriptive documentation, and vigilant claims tracking are key to ensure appropriate reimbursement for these services.

SYMPTOM-DRIVEN ICD-10 CODING

Palliative care providers are often consulted to assist with maximizing quality of life and minimizing suffering for the time a patient has left. In doing so, the goals of care often center around symptom control and not disease management. This may differ from the primary attending’s care plan, which may employ palliative services, but which are still overall managing a disease state. Use of ICD-10 codes for symptoms being managed, not only better reflects the work of the palliative care provider, but also ensures that different ICD-10 codes will be submitted from the primary physician’s claim. For example, a patient with end-stage COPD is admitted for the eighth time this year with a COPD exacerbation, contemplating hospice care, and most bothered by dyspnea and fatigue. The palliative care provider’s documentation and plan will focus on control of the symptoms of dyspnea and fatigue, while the primary hospitalist’s note will focus on appropriate management of COPD. Claims for these services will be submitted with the ICD-10 codes for dyspnea [R06.0] and fatigue [R53.83], and COPD [J44.1] respectively.

COMPLETE AND DESCRIPTIVE DOCUMENTATION

Palliative care providers often spend enormous amounts of time counseling patients, and may bill a significant percent of their visits based on CCC. More detailed descriptions of the clinical situation will better support the medical necessity to spend these larger amounts of time with the patient. Adjectives may make a huge difference. A statement such as “patient extremely distraught over their terminal condition and required intense counseling regarding goals of end of life care” paints a much better picture for the need for 90 minutes of counseling than a statement like “Patient upset over terminal diagnosis. I counseled the patient on goals of care.”

TRACK CLAIMS AND CLAIM DENIALS

The best way to prevent future denials is to determine the reason for denial of a medically necessary visit, and use information learned from that encounter to prevent a denial for similar services. For example, a private insurer who sees two inpatient follow-up services [99231-99233] from the same subspecialty group on the same calendar date, even with different ICD-10’s, may deny it upfront simply because they require modifier –25 to be attached to one of the services. Another provider may require documentation to be submitted upfront for all situations where two inpatient follow-up visits are submitted on the same date. Lessons learned from these two denials alone may prevent hundreds more.

One way to help track these services internally would be to remember to submit ICD-10 code [Z51.5] for “encounter for palliative care services” with 100% of these services. This code should never be the primary diagnosis. Its use will not alter the amount of reimbursement for the visit; however its presence on a claim may alert an insurer that this service is separate and distinct from another E/M submitted by the same billing group, and prevent an upfront denial. At minimum, it will allow a physician to more easily search for these encounters in their data base to monitor payment for these services.

SUGGESTED READINGS

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PROCEDURES

INTRODUCTION

Procedures are commonplace in hospital medicine; more and more hospitalists have invested additional educational time in becoming proficient in performing them. Understanding the documentation requirements necessary to ensure proper payment of procedures, including adequate documentation of the medical necessity to perform them, is crucial. In addition, making sure that the Current Procedural Terminology (CPT) code is correctly linked to the proper International Classification of Diseases, 10th Revision (ICD-10) code(s) will further prevent claim denials.

Details regarding the service requirements of each procedure are outlined in the CPT Handbook, published by the American Medical Association. The Medicare Claims Processing Manuel discusses nuances in Medicare guidelines regarding situational and documentation requirements for reimbursement. Procedures may be described as “minor” or “major.” These terms have caused significant confusion in the literature. There are actually two different ways in which the terms “minor” and “major” procedures are used within the Medicare manual.

MINOR VERSUS MAJOR PROCEDURES

Surgeries and global packages

Within the Medicare Processing Manual, procedures are referred to as “surgeries” or “surgical procedures.” When discussing payment for the medically necessary care provided immediately before and after the procedure, one must be aware of the global period associated with the service. Services with global periods of 90 days are defined as “major surgeries” or “major procedures.” These terms are used interchangeably in the manual. Services with global periods of 0 or 10 days are described as “minor surgeries” or “minor procedures.” Endoscopies are included in this category. Most procedures performed by nonsurgical specialties fall into the “minor” procedure category.

One example of the importance of this distinction is use of modifier –57 (decision to perform surgery). Modifier –57 is only used when deciding to perform major and not minor procedures. Reimbursement for all care related to the surgery, by the surgeon performing the procedure, occurring 1 day before the procedure and for the ensuing 90-day global period, is bundled into the reimbursement for the surgery’s CPT code. One exception is the reimbursement for the E/M visit at which time the decision to operate is made if it occurs 1 day prior to surgery or on the day of surgery. Modifier –57 attached to that E/M code will allow for its reimbursement in addition to the reimbursement for the major procedure. For the situation where the decision to perform a minor procedure is made at an E/M visit the same day of the procedure, modifier –25 should be attached to that E/M code to show that it was medically necessary work, separate from the usual history and physical needed to safely perform the procedure.

Teaching physician procedural billing

With regard to teaching physician (TP) rules for procedural billing, a “minor” procedure is defined as taking <5 minutes to perform, and the TP must be present for the entire procedure to bill for it. A “major” procedure takes >5 minutes. The TP must be present for the critical or key portion(s) of the procedure and must be immediately available for the entire procedure, in order to bill for it. The definition of “major” and “minor” in this context is based on the usual total procedure time. Examples of minor procedures include drainage of a subungal hematoma [11740], or a skin punch biopsy [11100]. Most inpatient procedures hospitalists perform, are considered “major” procedures, such as central line placement [36555-36556], thoracentesis [32554, 32555], or lumbar puncture [66270, 66272].

DESCRIPTION OF SELECTED PROCEDURES

Below are nuances of some common procedures performed in hospital medicine.

Central venous access procedures

Central venous access can be achieved through various locations and processes, and with various apparatuses. Different CPT codes exist based on the following key pieces of information: (1) location of access—central, peripheral; (2) method of placement—tunneled, nontunneled; (3) apparatus—catheter, port, pump; (4) number of access sites in the apparatus; and (5) age of the patient. Each of these factors plays a role in determining the usual amount of work needed to perform the service, which directly ties into graded reimbursement amounts. For example, tunneled catheters require more expertise and take longer to place than nontunneled lines; centrally placed lines are more challenging than their peripherally placed counterparts; and a device with a port takes more work to place than a catheter without one. There are separate codes for repair, replacement, and removal of these apparatuses as well (Table 29-1). These central venous catheters (CVC), also called “central lines,” and central venous access devices (CVAD), like “ports,” have tips that terminate in either the subclavian, brachiocephalic, innominate or iliac veins, or where one of these joins with the superior or inferior vena cava. Medical documentation should include these key pieces of information not only to select the correct CPT code, but also to adequately support reimbursement for these services. This information is usually found in a procedure note.

“Placing a central line” at bedside, by convention, has become synonymous with “placing a nontunneled catheter in a central location” such as the internal jugular vein or the subclavian vein. This corresponds to CPT codes [36555, 36556] which differ only by the age of the patient. In this example, to ensure accurate CPT code selection, at minimum, the body of the procedure note should include reference to insertion of a nontunneled catheter (such as a triple lumen) into a central vessel (such as the right subclavian). In addition, postprocedure chest x-ray results verifying tip location should be documented. The CPT codes for peripherally inserted central catheter (PICC) placement [36568, 36569] only differ by age of the patient.

Use of ultrasound guidance [76937] or fluoroscopy [77001] for placement, is reimbursed through an additional code and is not bundled into the reimbursement for central line placement. Billing for imaging used to guide line placement requires very specific documentation. Ultrasound guidance for central vascular access [76937] is only reimbursable when used with a “dynamic” technique and not a “static” technique. A dynamic technique implies that the ultrasound is used throughout the entire procedure, not only to identify the target vessel, but to watch successful entrance of the needle into it. “Static” use of the ultrasound purely identifies the vessel and its patency, and is not reimbursable.

At minimum, documentation needs to include a description of potential access sites, patency of the vessel selected, and successful entry of the seeker needle into the target vessel in order to bill for ultrasound guidance for central vascular access [76937]. In addition, permanent visual recording in the form of a printed image, digital image, or video must be captured and available in an audit. The CPT manual implies that at least an image of the patent target vessel is sufficient. Attempting to shift focus away from the procedure to try to capture an image of the actual seeker needle in the vessel may pose a risk to the patient. A postprocedural image of the catheter sitting in the target vessel would be a safer and acceptable way to meet these criteria. When submitting the claim, remember to attach modifier –26 to the CPT code since the technical component of the service is not separately reimbursable in a facility setting. Placement of a nontunneled Quinton triple lumen catheter into the right subclavian vein of a 45-year-old patient using dynamic real-time ultrasound guidance, would be reported using CPT codes 36556 PLUS 76937-26.

There is no reimbursement for repositioning or removing a nontunneled catheter at bedside. However, changing a nontunneled central line over a wire (central location [36580], PICC [36584]) is separately reimbursable. If a second line needs to be placed on the same day as the first (ie, the patient pulls the first one out completely, or the patient had a dialysis catheter placed on the same day as a triple lumen CVC), the CPT code for the procedure would be reported twice with the appropriate modifier (–76, –77) appended to the second procedure.

Thoracentesis and chest tube placement

The CPT codes for accessing the pleural space [32554-32557] were updated in 2013 to better reflect a change in practice with improved technology. At that time, over 75% of thoracenteses with or without catheter placement were being done with ultrasound guidance. This new set of CPT codes contains bundled codes, such that a separate CPT code for the use of imaging (ultrasound [76942], fluoroscopy [77002]) to identify a pocket of fluid, should no longer be submitted with the appropriate pleural access code; reimbursement for the use of imaging is already included in the payment for the primary procedure code [32555, 32557]. Documentation for a thoracentesis (“puncture and aspiration of the pleural cavity”) needs to specifically identify if ultrasound guidance was used [32555] or not [32554]. No adjustment in reimbursement is made for a diagnostic versus therapeutic procedure. Similarly, placement of a pigtail catheter (“percutaneous pleural drainage with insertion of indwelling catheter”) with ultrasound guidance [32557] reimburses higher than the blind placement [32556] (Table 29-2).

For chest tube placement [32551], if imaging guidance is used (ultrasound, fluoroscopy, computed tomography), a separate CPT code [75989] must still be submitted for reimbursement of imaging. The reason for higher reimbursement than pigtail catheter placement is that this open procedure requires cutdown and dissection. The procedure entails moderate sedation which is not separately reimbursable. Chest tube insertion is not separately reimbursable if placed intraoperatively during another cardiac or thoracic procedure.

There is no separate reimbursement for removal of chest tubes or pigtail catheters. If any of these procedures is done bilaterally, modifier –50 should be used.

Paracentesis

Just as for a thoracentesis, paracentesis codes [49082, 49083] were revised in 2012 to reflect the increased use of imaging guidance. The intent to do a diagnostic versus therapeutic procedure, the difference between small and large volume taps, and performing the initial versus subsequent tap, do not play a role in determining the level of reimbursement. For the higher level of reimbursement, documentation must clearly state that imaging was used, otherwise the reimbursement will default to the lower reimbursing service done without imaging [49082]. [49083] is a bundled code reimbursing for both the work of the procedure as well as the imaging. A separate CPT code such as 76942 (ultrasound guidance) should not be used with it (Table 29-3).

Incision and drainage

The selection of the correct CPT code for incision and drainage (I&D) procedures is based on the location of the lesion, on the type of lesion being treated, the complexity of the procedure, and if it occurred in the postoperative period. Certain locations have unique CPT codes for I&D such as an abscess of the eyelid [67700] or external ear [69000, 69005]. I&D of the majority of abscesses are reported using CPT codes 10060 (simple) and 10061 (complex or multiple). There is no universal definition of “complex”; the CPT manual states that it is left up to the clinical judgment of the provider and substantiated by their documentation. Complex I&D procedures include (1) large lesions, though “large” is also not universally defined; (2) significant packing or placement of a drain; (3) disintegration of loculations; (4) incision and drainage of multiple lesions. I&Ds of hematomas are reported with CPT code 10040 (Table 29-4).

MODIFIERS

A modifier is a two character alpha numeric code, attached to a CPT code, to further describe a service or to signify that a service has been altered by a specific circumstance without changing the description/definition of the service. Some situations require more than one modifier to be used with a CPT code. There are two levels of modifiers. Level 1 modifiers, also called CPT modifiers, are numeric, and updated by the American Medical Association. Level 2 modifiers, also called HCPCS modifiers, begin with a letter followed by either a number or another letter, and are updated by CMS.

There are hundreds of modifiers. Some directly impact reimbursement amounts; some directly enable payment for a service, while others are for informational purposes alone. Below are some of the more common ones needed for proper claims processing in Hospital Medicine.

MODIFIER –25: SIGNIFICANT AND SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PROVIDER ON THE SAME DAY AS A PROCEDURE OR OTHER SERVICE

This may only be attached to an E/M code and not to a procedure code. On occasion, it is necessary for a provider and/or covering member of their billing group, to provide more than one medically necessary service to a patient on the same calendar date.

E//M and procedure

The most common scenario would be a medically necessary E/M visit plus a procedure on the same calendar date. Modifier –25 should be attached to the E/M code to signify that it is a separately identifiable service, distinct from the routine pre- and postwork needed for the procedure. For example, a hospitalist admits a patient with altered mental status and fever, determines that a lumbar puncture (LP) is needed, and performs it on the same date as the admission. The hospital may receive payment for BOTH the initial inpatient visit [99221-99223] PLUS the LP [62270]. Modifier –25 should be attached to the initial inpatient visit CPT code [99221-99223] to show that the cognitive work of that visit is separate and above and beyond that necessary for just safely performing the LP. In contrast, a neurologist may only bill for the LP and not for an E/M visit, if his or her role is one of proceduralist and not consultant. A proceduralist should take and appropriately document a brief history and perform a brief physical preprocedure to ensure the safety and necessity of performing the procedure. A consultant is asked for and provides an opinion on diagnosis, evaluation, and treatment. A consultant can be reimbursed for both the consult that generated the decision to perform an LP plus the procedure.

Two E/M services

A modifier –25 may be needed when two medically necessary E/M services are provided on the same calendar date. Only one primary E/M code should be submitted for all E/M work done from 12:01 am to 11:59 pm by one physician and/or multiple physicians in a billing group functioning as coverage/continuance of care for each other. However, a few exceptions to this rule exist. One exception is when an E/M service such as an inpatient admission or inpatient follow-up visit is completed and followed later that same day by a critical care service by the same provider and/or billing group. The provider may be compensated for both services. Some insurers may require modifier –25 to be attached to the CPT code for the noncritical care service to show that it was separate and distinct from the critical care service. Medical necessity and complete documentation for both services must exist in the medical record.

MODIFIER –26: BILLING FOR THE PROFESSIONAL COMPONENT OF A PROCEDURE

Many procedures such as chest x-rays and ultrasounds have reimbursement that is divided into a technical component (TC) and a professional component (PC). Reimbursement for the TC covers the cost of purchasing or leasing equipment, and for maintenance. The reimbursement for the PC covers the supervision/performance of a test, and its formal written interpretation. When billing for the professional component of a service, attach modifier –26.

For example, many hospitalists read their own chest x-rays (CXR) to make immediate management decisions for their patients, and document their findings in their progress notes, followed by a formal or official radiology report some time later. This work counts toward their level of medical decision making for the E/M service and is not separately reimbursable. However, some institutions do not have radiologists immediately available after hours and may have a system in place whereby hospitalists or emergency department providers are responsible for producing the official written reports, not a radiologist the next day. In this situation, with a valid written report generated, this work is separately reimbursable by the hospitalist or emergency department provider. The TC of the global fee (total reimbursement) for the procedure, is not separately reimbursable in this setting. Modifier –26 should be added to the procedure’s CPT code for reimbursement of the PC. For the CXR above, 71020-26 would be submitted for reimbursement for the work of viewing and interpreting the film, and creating the official report. The provider cannot count that work toward the complexity of his medical decision making for any associated E/M service to the patient if receiving separate reimbursement for CXR interpretation. Minus one situation, in the erroneous event that both the hospitalist and a radiologist submit 71020-26 for reimbursement for the same film, only the first bill received with be reimbursed. A system needs to be in place to ensure that this situation does not occur.

There are some procedures that do not have a global fee divided into a TC and PC. Instead, there are separate CPT codes for billing for TC + PC, TC alone, or PC alone. For example, EKGs: CPT 93000 is for TC + PC, 93005 is for TC alone, and 93010 is for the PC alone.

MODIFIER –76: SAME EXACT PROCEDURE PERFORMED BY THE SAME PROVIDER ON THE SAME DATE

A procedural CPT code and never an E/M code is used when the same exact procedure is done twice on a patient on the same calendar date and/or during the procedure’s global period. For example, a hospitalist places a central line on a patient in the morning, the patient pulls it out, and the hospitalist places another one later that day. The central line CPT code [36556] would be reported twice, attaching modifier –76 to the second one. Likewise, you would report cardiopulmonary resuscitation CPR [92950] twice attaching modifier –76 to the second CPR billing code if a patient requires CPR at two different times in the day. Reimbursement for two procedures requires appropriate documentation of each procedure (ie, two notes with the time each procedure was performed).

A left knee arthrocentesis and a right shoulder arthrocentesis would not be coded using this modifier. Although an arthocentesis was performed in both locations, it is not the exact same procedure—one is of the knee and the other is of the shoulder. This would be coded using modifier –XE instead.

MODIFIER –77: SAME EXACT PROCEDURE PERFORMED ON THE SAME DATE BY A DIFFERENT PROVIDER

This modifier is used exactly like modifier –76 except when the same exact procedure is performed by a different provider on the same date.

MODIFIER –AI: PRINCIPAL ATTENDING PHYSICIAN OF RECORD

This modifier is used to identify the principal physician of record for the patient, ie the main physician overseeing care. Medicare stopped paying for inpatient consult codes [99251-99255] on January 1, 2010. All consultants seeing inpatients now bill their consult with the same initial inpatient visit codes [99221-99223] and initial skilled nursing facility codes [99304-99306] that the admitting attending uses. The –AI modifier (letter I, not number 1) will distinguish the admitting attending from all other consultants, but will not change the amount of reimbursement for the visit. By attaching it to the initial inpatient or skilled nursing visit code, it also aids CMS with identifying which physician will bill for discharge management services. Only attach it to the initial inpatient [99221-99223] or initial skilled nursing facility [99304-99306] visit codes. Do not attach it to any other CPT codes such as subsequent visits [99231-99233, 99307-99310], discharges [99238-99239, 99315-99316], or observation services [99217-99220; 99224-99226].

MODIFIER –GC: CARE PROVIDED IN PART BY A RESIDENT, SUPERVISED BY A TP

Attached modifier –GC to all services performed in conjunction with a resident (including interns and fellows) in a teaching situation, provided that the TP was present and personally participated in the critical or key component(s) of the encounter. It is not appropriate to attach to services performed in supervision of medical students.

MODIFIER –GV: CARE RELATED TO THE TERMINAL ILLNESS

The –GV modifier can only be attached to services rendered by a hospice patient’s primary attending if (1) the attending is not employed or paid by the hospice under any agreement and is not a volunteer, and (2) the care is for the patient’s terminal illness. This modifier is used to submit claims to Medicare Part B for reimbursement. It cannot be used by consultants, nor can it be used by the patient’s primary attending for care unrelated to the terminal illness.

MODIFIER –GW: CARE UNRELATED TO THE TERMINAL ILLNESS

Attach modifier –GW to services provided to a hospice patient when care is unrelated to the terminal illness.

MODIFIER –Q5: RECIPROCAL BILLING

Attach modifier –Q5 to services provided in a reciprocal billing arrangement. A reciprocal billing situation exists when two or more physicians from different billing entities agree to cover for each other in one’s absence. This agreement does not need to be in writing, but clearly understood between parties. The criteria for reciprocal billing are (1) the regular physician is unavailable; (2) the patient is seeking care from the regular physician; (3) the substitute physician does not cover for more than 60 consecutive days. The substitute physician, with one exception, is not a member of the regular physician’s billing group. These services are actually billed under the regular physician’s National Provider Identifier (NPI) number, attaching modifier –Q5 to each CPT service code. The reimbursement will go to the regular physician. Ideally, when the substitute physician needs time off, the regular physician will return the favor, and in the long run, reimbursement evens out. This arrangement is commonly used by solo practitioners, but may also be used by group practices who acquire coverage from a physician outside their billing group. Notice that the usual scenario: partners in a billing group and subspecialty cover for each other on weekends, holidays, and vacations, does not fit the definition of a reciprocal billing arrangement. In this scenario, the physician providing the service would simply submit charges under their own NPI number.

The hospice setting is an exception from the situation where the substitute physician is actually from the same billing group. Hospice patients select or are assigned a primary attending who oversees their care. Unlike the role of principal attending of record for other hospital inpatients, the role of primary hospice attending is specific to an individual provider, not to a billing group/subspecialty. In the event that the hospice attendings require coverage, such as weekend coverage, and one of their partners covers these patients, this is also considered a reciprocal billing arrangement. These services, provided by a partner in the same billing group, will be billed under the regular hospice attending’s NPI number with modifier –Q5 attached to each CPT code. Thus in a group practice, Dr Sub may be covering for Dr Hospice for the weekend. All services provided by Dr Sub to Dr Hospice’s regular inpatients will be billed under Dr Sub’s own NPI; however, those services provided by Dr Sub to hospice patients will be billed under Dr Hospice’s NPI, attaching modifier –Q5.

MODIFIER –Q6

Modifier –Q6 is attached to all services performed by a locum tenens provider (LT), with claims submitted under the regular physician’s NPI. Reimbursement will go to the regular physician. A LT has no practice of their own, and functions as an independent contractor, receiving payment on a fixed per diem or fee-for-time basis. They can only provide coverage for any individual physician for a consecutive not cumulative 60-day period, even if not providing care on all of those days. The 60-day period starts to the first day the LT provides services. If a physician returns to work for a period of time and needs to leave again, the locum tenens may provide coverage for another 60-day period. The only exception to the 60-day time period for Medicare patients is for coverage of a physician called to active duty—coverage time is unlimited. If a second physician in a group practice needs time off, the LT can provide a separate 60 days of coverage for that physician as well, regardless of the number of days of coverage they already served for the first physician.

Common reasons a physician may not be available, include pregnancy, illness, continuing medical education, and vacation. In a group practice setting, a physician may need to leave the practice, and the practice may employ a LT for up to 60 days while finding a replacement. The purpose of a LT is to provide temporary coverage for an existing physician. They cannot be used as temporary help to fill a newly created position while growing a practice.

LT is an attractive short term coverage option. They do not have to be enrolled in Medicare to provide services since the billing is under the regular physician’s NPI. LT can only be employed to substitute for an absent physician. They cannot be hired to cover an absent nonphysician provider (NPP). Also, they cannot be employed to cover an absent physician if the reason for absence is death. NPI numbers are deactivated upon death.

LT guidelines were created by Medicare, but private insurers and Medicaid may differ. For example, Texas Medicaid and Healthcare Partners has a 90 consecutive day LT limit. Some private insurers do not recognize LT services and require LTs to be credentialed through the normal new member process. It is imperative for this and all billing situations, to check with individual payors for deviations from the Medicare guidelines.

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TEACHING PHYSICIAN GUIDELINES

INTRODUCTION

Teaching physician (TP) guidelines date back to 1969 with the publication of Intermediary Letter 372, but did not come under serious scrutiny until 1995 when the results of the Office of the Inspector General’s (OIG) first physicians at teaching hospitals (PATH) audit resulted in a $30 million dollar settlement by the University of Pennsylvania. The audit revealed that there was insufficient documentation in the medical record that the TP was physically present and actively participated in the critical portions of the services billed. This index case prompted a nationwide PATH audit initiative, and on December 8, 1995, the Health Care Financing Administration (HCFA), now the Centers for Medicare and Medicaid Services (CMS), published in the Final Rule, more detailed instructions for documenting and billing for services in a teaching setting. The rules officially went into effect July 1, 1996 and were added to the Medicare Claims Processing Manual, Chapter 12, Section 100. These rules have had modifications and clarifications over the years, last in 2011. Although state Medicaid programs and private insurers often follow Medicare, there are individual differences among these programs, especially in regards to requirements for TP presence and TP documentation. This author suggests using this chapter as a starting point, but checking with local payers for deviation from these guidelines.

DEFINITIONS

The term “resident” in the Medicare Processing Manual refers to “… an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting ….” Of note, receiving a faculty or staff appointment, or being included in a hospital’s full time equivalency (FTE) count, in and of itself does not alter a resident’s status. For billing purposes, and for this chapter, the term “resident” includes interns and fellows, but not students.

A student is someone in an accredited educational program like a medical school, dental school, or school of osteopathy that is not an approved GME program. Medicare does not pay for student services.

A TP is a physician who is not another resident, who provides care to patients in conjunction with a resident. A TP does not need to have a faculty appointment, thus these regulations are also applicable to private practice physicians who work with residents. Finally, these guidelines are specifically for physicians, and are not applicable to nonphysician providers (NPP), discussed separately in the second part of this chapter.

PAYMENT FOR PHYSICIAN SERVICES PROVIDED IN A TEACHING SETTING

The reason that medical and surgical services provided only by residents, within the scope of their training program, cannot be reimbursed through the Medicare Physician Fee Schedule (MPFS), is because Medicare Part A already pays for resident services upfront through direct graduate medical education (DGME) and indirect medical education (IME) payments. In a teaching setting, these services may be reimbursed through the MPFS if the TP personally performs or is physically present while a resident performs the critical or key portions of the service, assuming that the documentation clearly reflects this.

EVALUATIONS AND MANAGEMENT SERVICES

Teaching physician presence

There are several common scenarios in which the TP provides services in tandem with a resident. The key feature in all of these is that the TP is physically present and has a face to face encounter with the patient on the date of service, personally performing all of the service or at minimum, the critical or key portions to allow for billing, regardless of the extent of care the resident provided.

1. The TP personally provides the service. There may be situations when a resident has a day off, or the TP has completed a service before the resident has seen a patient and/or has discussed it with the TP. The TP would document the service as they would in a nonteaching setting as there is no resident note to link to. In absence of a resident’s note, attempting to write an attestation alone without personally documenting elements of the history, physical, and medical decision making, is insufficient to support reimbursement for the service provided.

2. The TP personally provides the service at a different time on the same calendar date as the resident. An example of this situation would be when a resident sees a patient and provides a service like a subsequent inpatient visit [99231-99233], and later on the same date, the TP sees the patient and personally performs the service. Notice that the personal performance and not the personal documentation of the entire service is the main feature that allows the TP to bill for this service. If the documentation by the resident earlier in the day contains the same information that the TP personally obtained later, the TP does not have to redocument any of it. The TP needs to document a valid attestation statement linked to the resident’s note, plus any additional findings, discrepancies, or changes in clinical condition.

3. The resident performs the entire service, or at minimum the critical or key components in the physical presence of the TP, and the TP personally documents that he or she was present for the critical or key portions of the service. The clinical judgment of the TP determines the critical or key portion(s) of a service, based on standards of care, specifics of the service, and individual patients’ situational factors.

DOCUMENTATION REQUIREMENTS

For E/M services (excluding outpatient Primary Care Exception situations), at a minimum, TPs must personally document:

1. The TP was present. All E/M services in the context of hospital medicine require a face to face encounter with the billing TP on the date of service. If something prevents the TP from seeing the patient, such as the patient being in the operating room all day, or at a procedure during the only time frame that the TP is available that day, even though the TP may have invested the time in complete data review, discussion with consultants, and care plan development with the resident, the service cannot be billed or reimbursed.

2. The TP personally performed the service or was present for the critical or key portions performed by a resident.

3. The TP participated in the management of the patient. In a teaching setting, the TP’s management of the patient is often not the direct writing of orders or calling of consultants. Instead, care plan development and supervision of proper execution or orders are commonplace: review of the resident’s documented assessment and plan for accuracy, discussion with the resident of the details of the plan, including any deviances from their documentation, and vigilant follow-up to ensure timely and correct follow-through of the plan. Documentation of these activities will satisfy these criteria.

These three criteria are often documented in a sentence called an “attestation statement.” This statement must always be written by the TP. The resident’s documentation of the presence and participation of the TP is insufficient to support reimbursement for the service. An acceptable attestation correctly linking the TP’s note to the resident’s note will allow for the combination of the resident’s and the TP’s documentation to determine the level of service provided.

Medicare manual examples of unacceptable attestation statements that do not meet the above criteria include the following statements which do not make it possible to determine if the TP was actually present, evaluated the patient, and/or participated in the plan of care.

1. “Agree with above.” followed by valid authentication (ie, legible signature or electronic password protected signature).

2. “Rounded, Reviewed, Agree.” followed by valid authentication.

3. “Discussed with resident. Agree.” followed by valid authentication.

4. “Seen and agree.” followed by valid authentication.

5. “Patient seen and evaluated.” followed by valid authentication.

6. Valid authentication alone.

In addition, a TP’s attestation statement referencing a resident’s note but written and signed before the resident’s note is written will not allow linkage to the resident’s documentation, and thus not allow the resident’s documentation to be used to determine the level of service provided. You cannot attest to reviewing and agreeing with documentation that has yet to be written.

Examples from the Medicare manual of minimally acceptable attestations include:

1. “Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”

2. “I saw the patient with the resident and agree with the resident’s findings and plan.”

3. “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plan as written.”

Although not specifically stated in the Medicare manual as a requirement, the use of the word “I” at the beginning of the attestation is the best way to document that you personally performed the service.

In addition to the attestation statement, the TP should document any information that the resident forgot to document, new information or changes in clinical picture since the time of the resident’s note, as well as any discrepancies or disagreements with the resident’s findings, thoughts, or plans. This not only helps support billing, but more importantly, high-quality patient care as well. Below are a couple examples of this from the Medicare manual:

1. “Hospital Day #5. I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”

2. “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

In fact, this additional documentation, individualizing the documentation to each patient, is better verification of the TP personal participation in the case.

STUDENT E/M DOCUMENTATION

The only parts of a student’s documentation that may be referred to and used to determine the level of E/M service provided, are the review of systems (ROS) and past medical history, family history, and social history (PFSH). The TP note must document their review and agreement with the information. No matter how accurate and complete a student’s documentation of the history of present illness (HPI), physical exam (PE), and medical decision making (MDM), reference to it without the TP personally verifying and redocumenting it, will not allow it to contribute to a billable service.

LATE NIGHT ADMISSIONS

In all of the above examples, the understanding is that the TP and resident performed a service jointly on the same calendar date. The TP can only link their attestation to the resident’s documentation from the same calendar date, and thus use it to determine their level of service. There is one special exception to this rule. In the teaching setting, it is not uncommon for a resident to admit a patient late at night when there is no TP in the facility to immediately provide the initial inpatient service. In 2010, the author of this chapter worked directly with CMS to augment the Medicare manual to include this scenario. In 2011, this scenario was added to the Medicare manual allowing a TP to link their attestation statement to the resident’s documentation of the initial inpatient visit the night before, allowing that documentation to be used to determine the level of service, provided that the TP also documents any additional information or significant changes since the time of the resident’s note. The date of the service for claim submission should be the date that the TP actually had their initial face to face visit, even if it is different from the patient’s admission date.

PROCEDURES

There is some confusion and controversy over TP documentation requirements for procedures due to the way the Medicare manual is worded. In addition, with the wide variability in state Medicaid and private insurer regulations, many compliance offices opt for more defendable approaches than what seems to be required in the Medicare manual, to ensure documentation meets any entity’s strictest regulations. The Medicare manual uses the terms “procedure” and “surgery” interchangeably at times, making the guidelines for TP documentation in certain circumstances, left up to interpretation. For all “surgical procedures,” the manual is clear that the TP must be present for the critical or key components of the procedure, but no blanket statement is made regarding TP documentation requirements.

Single surgeries

In order to bill for these services, a TP must be physically present for the critical or key components, plus for the noncritical portions, the TP must be immediately available to return if needed. If the TP is unavailable for the noncritical components, they need to make arrangements for another qualified physician to be available. If the TP is present for the entire procedure, the resident or operating room nurse may document the TP’s presence without need for the TP to personally document it. The manual does not elaborate on the TP documentation requirements if the TP is only present for the critical or key components of a single surgery. In this situation, check with institutional compliance office regulations regarding if the TP needs to personally document their presence versus having the resident or operating nurse’s documentation of their presence satisfy billing criteria.

Two overlapping surgeries

In order to bill for each of two overlapping surgeries, the TP must be physically present for the critical or key components of each surgery. Thus, the critical or key components cannot overlap. They must also be immediately available to intervene for the noncritical components of each surgery. They must arrange for another qualified physician to be available for the noncritical components of the other surgery if they are not available for the noncritical components of one surgery (ie, they are in the second surgery during its critical or key components). The TP must personally document that they were present for the critical or key components of each surgery to bill for them.

Three or more overlapping surgeries

If a TP is involved in three or more overlapping surgeries, they cannot bill for any of those services.

Minor versus major

In the context of discussions about extent of TP participation in a procedure, one must determine if the procedure is “minor” or “major.” In this context, a “minor” procedure is defined as taking <5 minutes to perform. By default, a major procedure takes >5 minutes to perform. The vast majority of Hospital Medicine procedures are major. For minor procedures, the TP must be present for the entire procedure to allow for reimbursement. For major procedures, the TP needs to be present for the critical or key portions to bill for the service. Although the procedure note may be written by the resident, the TP must personally attest to their presence for the entire procedure or for the critical or key portions of the procedure, for minor and major procedures respectively. The resident’s reference to their presence is insufficient.

ENDOSCOPIES

The TP must be physically present for the entire viewing time (insertion of endoscope until removal of endoscope) to bill for endoscopic procedures. Viewing the procedure from a monitor in a different room does not meet criteria for TP physical presence. Because endoscopies are discussed in the Medicare manual in the same section as single surgeries, it is unclear if they follow the guidelines for single surgeries, meaning that it is not explicitly stated that the resident or the operating room nurse may document the TP’s presence in lieu of the TP personally documenting it. This is another situation to clarify with the institution’s compliance office.

TIME-BASED SERVICES

When a resident is involved in a service that is billed based on time, to meet minimum time requirements, the TP can only count their personal time spent, not the resident’s time spent. For example, if a resident spends 25 minutes on discharge management services for an inpatient, and the TP spends another 10 minutes, the TP cannot aggregate their documentation of time with the resident’s time to achieve 35 minutes of time, enough for the higher level of discharge service [99239]. The TP can only bill for the 10 minutes of time they personally spent on the encounter and thus only bill for the <30 minutes discharge service [99238].

CRITICAL CARE

When providing critical care services in conjunction with a resident, just as in other time-based services, the TP may only count personal time spent providing critical care to the patient, and not time spent by the resident. Time spent rounding and teaching, but not in direct patient care also cannot be counted toward critical care time. In addition, the TP can only bill for critical care services if the patient was critically ill during the time the TP was physically present and managing the patient. For example, if the patient is critically ill, going into impending respiratory failure, and the TP is not physically at the hospital, but assists the resident over the telephone in deciding to initiate noninvasive ventilation, order blood gases, and consult the intensive care unit, this time cannot be counted toward critical care, as the TP was not physically present providing the critical care service. More importantly, if the patient is off noninvasive ventilation and oxygen, breathing normally, and clinically no longer at risk of impending organ failure at the time the TP finally has their face to face visit, the TP still cannot bill for critical care since the patient did not require critical cares services at the time of the TP’s physical presence.

Although the resident’s documentation of the patient’s critical condition and their details of the history, physical, and high complexity of medical decision making all greatly support the medical necessity for critical care billing, in addition to a valid TP attestation statement, the TP must personally document their physical presence while the patient was critically ill, the amount of time they personally spent providing critical care, and a brief summary of their activities. The resident’s documentation of the TP’s presence and participation is insufficient to support billing for critical care services.

MODIFIER –GC

Attach modifier –GC to all services’ CPT codes when performed in conjunction with a trainee. By attaching modifier –GC, the TP is attesting to meeting all physical presence and documentation requirements to bill for these services.

MIDLEVEL PROVIDERS

INTRODUCTION

Advanced practice providers (APPs) including physicians are trained, licensed clinicians who can provide medical services. Some nonphysician providers (NPPs) may work and bill independently, such as nurse practitioners (NP) and physical therapists (PT). Others may only work under the direct supervision of a physician, such as physician assistants (PA). Other health care workers that fall under the term NPP include: certified registered nurse anesthetists (CRNA), certified nurse midwives (CNM), clinical nurse specialists (CNS), clinical psychologists (PhD), nonclinical psychologists, occupational therapists, and speech pathologists. Medicare has very specific rules that govern how services involving an NPP can be provided and how they can be reimbursed. However, each state’s Medicaid program, and private insurers have their own regulations which may differ from Medicare. For example, some private insurers such as Aetna will only allow PAs to bill incident to a physician, not under their own license. This chapter will discuss NPP billing with regard to Medicare guidelines. Clinicians should check with individual state Medicaid programs and private payers for deviations from the information below.

NPPs must have their own National Provider Identification (NPI) number in order to bill Medicare. When NPPs bill under their own license, Medicare reimbursement is at 85% of the MPFS rate. Certain NPPs, including NPs, PAs, and CNSs, can provide evaluation and management (E/M) services in tandem with a physician, billing under the physician’s license, and allowing 100% MPFS reimbursement, in two very specific ways.

NPP REQUIREMENTS

In addition to meeting state licensing and credentialing requirements, in order to allow NPPs to bill under the supervising physician’s license, these two criteria need to be fully satisfied.

1. The NPP must be a financial responsibility to the billing physician and/or their group. Often the NPPs and the physicians are employed and paid by the same financial entity; they are members of the same group practice. Sometimes a physician group may directly hire an NPP or NPP group to work with them as an employee or as an independent contractor. In the event that the NPP is not the financial responsibility of the physician they are working with, this criteria will not be satisfied. An example of this type of relationship would be a private hospitalist group working with an NPP directly employed by the hospital. The hospital would usually report the NPP’s salary and benefits on their cost report. In this situation, the work of the NPP is not separately reimbursable, and thus any contribution by the NPP to a service performed with a physician, cannot be aggregated with the physician’s work to determine the level of service provided.

2. The service being provided by the NPP must be within the scope of their practice as defined by laws of the state they are practicing in, and in accordance with the Collaborate Billing Agreement with their supervising physician(s). These agreements are usually reviewed and signed annually, based on state regulations.

E/M SERVICES PROVIDED IN CONJUNCTION WITH A PHYSICIAN

SPLIT/SHARED BILLING

Service requirements

When an NPP and a physician each provide a “substantive” face to face portion of an E/M service on the same calendar date, the service may be billed under either the NPP or the physician’s NPI. Medicare does not define what exactly constitutes a “substantive” portion of the visit. It is expected however that a “substantive” portion will include all or some portion of history, physical, and/or medical decision making. There is no required percentage of the service that has to be provided and documented by the physician versus the NPP in order to bill under the physician’s NPI. The NPP and the physician must each personally document their portion of the E/M service in the medical record, and sign it. The level of service will be determined by the aggregate of their documented work.

Documentation requirements

The medical record needs to clearly reflect that both the NPP and the physician each had a face to face encounter with the patient on the date of service. Both NPP and physician must personally document their work in the medical record, both must be identified in the chart and provide valid signatures, and the two documentation entries must be linked to show that the aggregate of the documentation will be used to determine the level of service provided.

There are two key features to the billing physician’s documentation to ensure proper support for billing under their NPI in a split/shared situation.

1. The billing physician’s documentation should reflect that the physician had a face to face visit with the patient on the date of service, unlike “incident to” services which may be billed without the physician having a face to face visit. The physician’s personal entry in the medical record of their work, plus a valid signature constitute evidence of the face to face visit.

2. The billing physician’s documentation should reflect the medically necessary and unique contribution to the patient’s evaluation and care plan development. In contradistinction to visits in conjunction with a resident, where the billing TP must personally perform the critical and key portions of the service, in a split/shared service, the billing physician does not need to perform or attest to performing the critical and key portions of the service. Instead, the billing physician needs to personally document exactly what they obtained for history and physical, and their thoughts related to medical decision making. Examples of insufficient documentation of a substantive portion of work being done by the physician include:

   1. A notation by the NPP of the physician’s involvement.

   2. A simple cosignature of the NPP’s note.

   3. The billing physician’s documentation should not look like a TP attestation statement. Although the billing physician does play a supervisory role in their relationship with the NPP, and from an institutional policy, may need to make comment about reviewing the NPP’s work for legal purposes, the billing physician’s documentation should not look like they did nothing more than review and agree with the NPP’s work and documentation.

In the above three documentation scenarios, the service may only be billed under the NPP’s NPI.

The roles of the NPP and physician should be complementary; the relationship between a billing physician and an NPP in a split/shared visit is similar to two colleagues covering for each other, seeing a patient sequentially on a given day. There will inevitably be overlap in the historical, physical exam, and decision-making information obtained and documented; however, the documentation needs to clearly reflect that the NPP and physician each contributed unique and medically necessary care. Specifically, the physician documentation needs to reflect their independent contribution to the care of the patient outside the work of the NPP. When the physician sees the patient earlier in the day and documents their encounter before the NPP, their contribution to the service is more easily discerned. In the scenario where the NPP sees the patient and documents their encounter first, by remembering to document additional historical information, physical exam findings, new information since the NPP’s visit, changes in clinical status, and additional medical decision making not reflected in the NPP’s note, the medical necessity of the physician’s role in the service is better supported.

Split/shared services can only be provided in the hospital inpatient, hospital outpatient (Place of Service, POS 22), hospital observation, emergency room, and nonhospital based (private) office settings. In order for split/shared services to be performed in a private office setting (POS 11), “incident to” criteria must be met, thus new patient visits [99201-99205] in the private office setting can never be billed as split/shared visits (see section “incident to”). Note that new patient visits can be billed in a hospital based clinic since “incident to” rules do not apply to hospital settings and are thus not a requirement for these services in that setting. Below is a summary of services that can and cannot be performed with split/shared billing (see Table 30-1).

The aggregate work in a split/shared service follows CPT E/M rules such that work is added up from 12:01 am to 11:59 pm, and not over a 24-hour period. If the NPP sees a patient at 10 pm, for example and performs the work of admission, but the physician does not see the patient until 8 am the next morning, the physician cannot aggregate his work the next calendar date with the NPP’s from the night before to submit a claim as a split/shared service. The TP rules for late night admissions do not hold true for split/shared services. The NPP would bill the admission (initial inpatient visit [99221-99223]) under her or his own NPI, not the physician’s NPI, on calendar date 1, and physician’s work the next morning will go toward determining the level of E/M service on day 2, such as a subsequent inpatient visit [99231-99233].

CONSULTS

Although Medicare’s guidelines do not allow consult services to be billed as split/shared visits, since January 1, 2010 Medicare no longer recognizes or reimburses for consult codes [99241-99255]. Medicare however still pays for consult services, just through different code sets [99221-99223; 99231-99232; 99201-99215; 99281-99285]. All of these code sets may be billed as split/shared services. So now for Medicare patients, even though the intent of the service is to provide a consult, when submitted with one of these services codes, the care may now be provided as a split/shared visit. Clinicians should check with Medicaid and private insurers for how these services should be billed.

INCIDENT TO

“Incident to” services are defined as medically necessary services that are provided incident to a physician’s professional services, but are an integral part of the plan of care. “Incident to” services can only be provided in a nonhospital based (private) office (POS 11) or patient’s home, but never in a hospital setting. Several criteria must hold true to allow for this billing.

1. The care by the NPP is provided under the direct supervision of the physician. The physician must have had an initial face to face visit with the patient at some previous point in time to establish a plan of care, with the intent of the NPP carrying out the plan of care at (a) subsequent visit(s). Thus “incident to” services can never be provided to new patients or to established patients with a new problem. If a patient presents for planned follow-up with the NPP, and in the course of the visit, in addition to the expected problem with an established plan of care, the NPP uncovers a new problem, the NPP must now bill the entire encounter under their own NPI.

2. The physician must stay active in the patient’s care. Usually this is satisfied by the physician seeing the patient at intervals to review, revise, or update the plan of care. The interval of time between physician visits is left up to the clinical judgment of the physician, the specific patient needs, and standards of care.

3. The physician must be physically present in the office or suite and be immediately available during the time the NPP provides the service. The physician does not have to be physically present inside the individual treatment room with the NPP and patient. It is helpful to keep records of physician schedules in the event of an audit to aid in supporting their presence. If however the physician must leave the office while the NPP is providing a planned “incident to” service, if the physician’s partner is physically present in the office and immediately available to cover, the visit can still be submitted under the physician as an “incident to” service. Otherwise, the visit must be billed under the NPP’s NPI.

Incident to services do not require the billing physician to have a face to face visit with the patient on the date of service. In addition, for billing purposes, “incident to” services do not require the supervising physician to document anything in the medical record. However, based on physician comfort level, and certain state or individual institution internal policies, the supervising physician may need to sign each note. No modifier is necessary for submitting these claims.

SCRIBES

Occasionally practices employ NPPs as scribes. A scribe’s role is to document an encounter for a physician, in the medical record. Scribing is not reimbursable. Scribes are not allowed to enhance or alter documentation to improve billing, nor can they add their opinions or personal observations. When using a scribe, the documentation must be very clear that the scribe “A” is functioning purely to document physician “B’s” findings and plans. Practices that employ NPPs as scribes need to be very careful to have protocols in place to ensure that the documentation clearly reflects the physician’s work, and not the clinical work of the NPP while serving as scribe. Physician B needs to attest that the documentation of history, physical and decision making reflects his own personal work.

ONLINE RESOURCES

INTRODUCTION

The documentation of the inpatient episode of care follows the general principles outlined in Chapter 27: Professional Billing and Coding, and is primarily a record of the patient’s clinical experience. A number of regulatory changes in the payment for hospital facility care have occurred over the past decades which subtly change the documentation requirements and may lead to increased interactions of hospitalists with others in the hospital systems such as clinical documentation improvement (CDI) and utilization review (UR) personnel. A better understanding of these regulatory changes and their impact on both facility reimbursement and patient financial liability will help the hospitalist document care more completely. In addition, there will be fewer interruptions and queries, less back-end work for facilities and fewer surprises for the patients when their hospital bills arrive.

DIAGNOSTIC RELATED GROUPS AND PAYMENT FOR HOSPITAL SERVICES

Predetermined payment based on diagnosis

Medicare pays hospitals for inpatient services using the inpatient prospective payment system (IPPS). Although IPPS is only applicable to Medicare, the concept of prospective payment for inpatient stays has been adopted by most third party payers. The primary driver of payment in the inpatient setting is a grouping methodology, called a diagnostic related group (DRG).

The basic premise of a DRG system is prospective payment, or a predetermined, fixed amount. The original DRG system began in the early 1980s in some states, with congress implementing the IPPS for Medicare services in 1983. Prior to the introduction of the DRG system, hospital reimbursement was made on a percentage of costs, and hospitals billed for the actual costs for an inpatient admission and received a true “fee for service.”

Each DRG payment is based upon an analysis of prior claims data in regard to how much it costs, and how many resources are required on average, to treat patients of that type. There are modifications to this payment amount for hospitals based on location, the percentage of low income patients treated, teaching hospital status, and whether or not the specific case was “unusually costly.” DRGs are three digit numerical assignments which are divided into categories, called major diagnostic categories (MDCs) based upon the patient’s symptoms, comorbidities, whether the care provided was medical or surgical, the organ system affected, age, and discharge status. Each DRG was intended to be a reflection of the resources required to care for patients in specific categories, and is designed to make one single payment to cover all of the services provided by the facility during the inpatient stay.

Modification of the DRG system

There were initially many limitations to the DRG system, as it was developed for use with a Medicare population and had limited applicability to other populations of patients, most notably children and expectant mothers. As a result, many private payers began using a modification of the DRG system called the All Patient Refined DRG system, or an APR-DRG. This was the first introduction of adjustments for patient severity of illness and the intensity of resources needed to care for specific patients who had multiple conditions which represent significant comorbidities and thus intensified resource requirements.

On October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) followed suit and introduced the MS-DRG system: the Medicare Severity DRG. Upon initial implementation, the MS-DRG system changed the number of available code assignments from 500 to 746. The increase in the number of possible code assignments was a reflection of the introduction of major complications or comorbidities (MCCs), complications or comorbidities (CCs), or noncomplications or comorbidities (non-CCs).

ICD-9/ICD-10 codes

Each year, CMS produces lists of ICD-9/ICD-10 codes which are designated as major comorbid conditions (MCCs) or comorbid conditions (CCs) which impact the severity and increase the payment of a DRG. Frequently, physician education is centered around these concepts to ensure that physicians are adequately documenting these diagnostic categories so the hospital can be paid appropriately for services they have provided to patients and the hospital is able to report the most appropriate DRG on the claim.

Although the concept of DRG coding sounds simple, it may be very tricky for patients with multiple, complicated conditions. Documentation by the treating physicians is the key to understanding the principal diagnosis. The medical record must contain sufficient clarity for a coder to determine which diagnosis is principal. Frequently, a physician may not know what the principal diagnosis is, especially at the beginning of an admission when a patient presents with undefined symptoms. It is also common for a patient to be discharged without a definitive diagnosis, in which case the symptom treated becomes the principal diagnosis.

Coders determine the DRG code. The coder abstracts, or reads the medical record, and determines which diagnosis was the principal diagnosis for the hospitalization. According to the Official Guidelines for Coding and Reporting, the Principal Diagnosis is the “condition, after study, which occasioned the admission to the hospital.” This principal diagnosis assists the coder in determining the category of the MS-DRG code. The other two main factors in determining the proper DRG assignment are (1) whether or not a surgical procedure was completed during the stay, and (2) whether or not there are complicating or comorbid conditions present. When a coder is unclear about what the documentation is attempting to convey, he/she will submit a query to the physician. Many physicians have expressed consternation at the lack of clarity in coder queries; specifically that it is unclear what the coders are asking of the physicians. Because it could be financially advantageous to the facility for a physician to document a specific diagnosis, there are professional standards regarding the wording of queries which are not “leading” the physician to answer a certain way. For example:

• Documentation states, “Obtunded patient admitted with 3-day history of nausea and vomiting. CXR revealed right lower lobe (RLL) pneumonia. Clindamycin ordered.”

• Inappropriate Query, “Is the patient’s pneumonia due to aspiration?”

• Appropriate Query, “Can you specify the etiology of the patient’s pneumonia? It is noted in the admitting H&P this obtunded patient had a history of nausea and vomiting prior to admission. If the etiology of the pneumonia can be further specified, please document the type/etiology of the pneumonia in the progress note.”

Hospital payment is directly tied to the quality of the clinical documentation provided by the practitioners treating the patient. In the inpatient setting, there are many coding rules regarding what documentation can be utilized, and although there are exceptions to this rule, in general, the patient’s attending documentation carries the final weight if there are inconsistencies or contradictions regarding the patient’s diagnosis from residents, consultants or specialists.

OBSERVATION STATUS

Short hospital stays

Observation status applies to conditions that do not meet criteria as an inpatient, but it is otherwise inappropriate to send the patient home. Observation is considered an outpatient stay in the hospital and is reimbursed under Medicare Part B. This distinction means that a patient will have to pay a coinsurance, which is generally 20% for Medicare patients. Out of pocket costs can go up significantly when they are paying a percentage of Medicare approved charges. Additionally, patients who are classified as outpatients are not eligible for coverage for a Skilled Nursing Facility (SNF) by Medicare.

Hospitals began using observation services almost immediately after the IPPS was introduced in 1983. A problem with a capitated system of inpatient hospital payment began to surface, specifically what to do with cases which were short stays and did not approach the median length of stay for a particular DRG, but still fell into that DRG. Patients and their hospital care began to fall into the gap between what was expected as an inpatient admission and what was expected as an outpatient service. As part of this, there became three distinct categories for patients: Inpatient, Outpatient, and Observation.

Review of observation status

In the late 1980s and early 1990s, organizations called Peer Review Organizations, or PROs, reviewed admission decisions by providers and questioned the validity of the provider’s decision. This resulted in providers keeping patients in observation status for weeks at a time rather than risk admitting a patient who did not quite meet inpatient criteria. This resulted in excessive charges to Medicare and to the Medicare beneficiary, as outpatient stays for Medicare are billed as a coinsurance (20%, copay for instance) while the beneficiary charges for an inpatient stay are a set amount called the deductible ($1260 deductible in 2015). As a response CMS implemented a 48-hour target for observation services stating that it would be “unusual” for a patient to stay in observation longer. Currently, the CMS manuals state, “Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”

Issues with observation status

Observation status has been problematic for many hospitals from both operational and payment perspectives. CMS has issued additional instruction on the use of observation services almost every year for the past 20 years. Each year, they have changed the rules and the payment modeling slightly. For a period of time in the early 2000s, hospitals could only receive additional observation payments for patients who had congestive heart failure, chest pain, or asthma, as CMS had recognized that those were the categories most likely to require a longer assessment than an Emergency Room visit, but a shorter visit than the average inpatient admission for those conditions. Several years later, CMS reversed this policy and implemented different policies allowing any patient with any condition to be treated under observation, but they would only pay the hospital if the stay lasted at least 8 hours.

RECOVERY AUDIT CONTRACTORS

Further changes in the payment and definition of inpatient services for Medicare beneficiaries were largely shaped by the actions of and reactions to the Recovery Audit Contractor program.

Congress created the Recovery Audit Contractors (RACs) in 2003 as part of the Medicare Modernization Act (MMA) to recover underpayments and discover overpayments to the Medicare Trust Fund. The RAC program began as a demonstration project in selected states (NY, FL, SC, CA, MA, and AZ). From 2005 to 2008, the program recovered nearly $38 million in overpayments to the Medicare Trust fund, although these numbers may not include claims that were appealed. In 2006, Congress wrote into law (Tax Relief and Health Care Act of 2006) a permanent and national Recovery Audit Program to recoup overpayments associated with services made under part A or B of title XVIII of the Social Security Act (Medicare payments). While the RACs reviewed a number of areas of potential overpayments, the largest area by dollar amount was short-stay (1-3 days) inpatient hospitalizations. The records for these hospitalizations were reviewed, and the DRG payments denied and recouped, with the rationale “inpatient stay not reasonable and necessary, services could have been provided in an outpatient or observation setting.” The full payment amount was recouped, and the facilities had no mechanism for recovering a portion or the entire payment amount except to appeal inpatient denial. Even if the facility agreed that the patient could have received the service as an outpatient, or in observation status, to agree to this meant forfeiting all of the DRG payment. This lead to an unprecedented number of appeals by facilities around the country, and the federal appeal system was overwhelmed. The result was a backlog of appeals being processed, and millions of dollars tied up in the appeal system.

In March 2013, CMS issued an interim ruling which allowed facilities to rebill Part A claims which were denied by a CMS contractor for the inpatient admission deemed “not reasonable and necessary,” to Part B. In addition, they released a proposed rule defining which services could be rebilled under Part B. This proposed rule increased the number of services that could be rebilled for Part B payments, making this “Part B rebill” an attractive option in certain circumstances. In essence, the rule allowed facilities to rebill the denied inpatient claim as if the services had originally been provided in an outpatient setting/status. Later in 2013, the IPPS (IPPS) proposed and then Final Rules (1599-F) wrote into law a new definition of “inpatient” for Medicare Beneficiaries, and the “two Midnight Rule” was born.

TWO MIDNIGHT RULE AND PROBE AND EDUCATE AUDITS

On October 1, 2013, the two midnight (2MN) rule took effect for Medicare Beneficiaries, and the RAC audits for short stays were placed on temporary hold. The definition of an inpatient changed from a subjective one of potential risk and intensity of service, to a mostly objective time-based payment model. Per CMS: If a Medicare beneficiary requires medically necessary hospital services for two or more midnights, then the facility may bill for the services under Part A, as a DRG. If the patient is expected to require only 1MN of services, the provider should place the patient in observation, and the facility should bill for the stay under Part B. The only statutory exception is a patient receiving a procedure on the Medicare inpatient-only list. These patients must receive their care as an inpatient in order for the facility to receive payment for the surgical procedure.

There are certainly nuances to this rule. The most straightforward are the exceptions to the 2MN timeframe. These include: patients who leave Against Medical Advice (AMA) prior to the second MN; patients who die unexpectedly; patients who are discharged to hospice unexpectedly; patients requiring new, unexpected mechanical ventilation; and patients who have an unexpected clinical improvement and are discharged prior to the second MN. CMS is clear that these exceptions should be rare, and that documentation would need to support the Part A billing of 1MN stays in these circumstances.

Another change was start time for the 2MN. The clock starts at the time the patient begins to receive care at the facility, regardless of the time of the inpatient order. For instance, time in the emergency department, in observation, in the clinics, in the operating room or other procedures all count toward to the 2MN. In addition, if a patient is transferred from an outside facility, the accepting facility can count the time spent in the outside facility’s ED toward the 2MNs. One example: if a patient is originally placed in observation because he is not expected to require 2MN of care, but does not recover as expected and requires an additional night of medically necessary hospital services, the order can be changed to inpatient on hospital day #2, and the entire stay can be billed under Part A because the patient stayed in the facility for a total of 3 days and 2MN. However, to qualify for skilled nursing facility care, the beneficiary must still have a three midnight inpatient hospitalization, specifically, three midnights after an inpatient admission order. In the example above, only one midnight was spent in the facility after the inpatient order was written, therefore only one midnight would count toward the SNF qualifying stay.

The 2MN rule defined several new terms, the 2MN presumption, the 2MN expectation and the 2MN benchmark. The presumption essentially states that medical reviewers (auditors), in the absence of evidence of gaming, should not review claims for patients who receive 2MN of hospital care after the inpatient order, as it will be presumed that the inpatient admission was reasonable and necessary. The 2MN expectation and 2MN benchmark are used interchangeably. These terms define the premise under which the admitting provider makes the decision to write an admission order, using the information available at the time of admission. That is, physicians and other providers should generally admit as inpatients the Medicare beneficiaries they expect will require two or more midnights of hospital services, and should treat most other beneficiaries on an outpatient or observation basis.

The 2MN rule was and is a departure from the previous method of determining inpatient status, which involved screening criteria of severity of illness and intensity of service. And, this rule applies to Medicare beneficiaries only, not other payers. In order to help providers and facilities understand the rule, and allow CMS to determine the need for more education, they immediately instituted a “probe and educate” period for all facilities. CMS instructed the Medicare Administrative Contractors (MACs) to review a small sample of Medicare Part A inpatient hospital claims spanning 0 or 1 midnight after formal inpatient admission to determine the medical necessity of the inpatient status in accordance with the 2MN benchmark. Each facility then received feedback, and if required, a second sampling of 1MN stays. This process required more time than originally expected, and the probe and educate period was extended, from March 2014 to September 2014, then March 2015, April 2015, and most recently to September 2015. During this period, the RAC audits for medical necessity related to inpatient status were placed on hold, and all admissions during this period are prohibited from future review related to inpatient status by the Recovery Audit Contractors.

CERTIFICATION REQUIREMENTS

In addition to the 2MN rule, the 2014 IPPS final rule (1599-F) outlined new certification requirements for all inpatient hospitalizations. While certification was not a new concept, it had been in place primarily for long stays and payment outliers. For 14 months, until most of the Certification requirements for all inpatient admissions were removed in January 2015, many hospitals and providers scrambled to understand and comply with the certification requirements. As of January 1, 2015, the only portion of these short-lived requirements which remained for all inpatient hospitalizations was the inpatient order requirement. CMS defined the admission order requirements in the Code of Federal Regulations, making this a condition of payment in federal law under Medicare Part A. The inpatient admission order must be present in the medical record, and supported by admission and progress notes. The order must be “furnished by a qualified and licensed practitioner who has admitting privileges at the hospital as permitted by state law.” Other requirements include familiarity with the patient’s case, and the timing of the order should be at or before the time of inpatient admission. The regulations specifically state that the admitting practitioner cannot delegate the order to another individual who does not meet the criteria, but subregulatory guidance does address trainees and verbal admission orders. The expectation is that any inpatient admission order placed by a resident, mid-level provider (without admitting privileges) or verbal inpatient admission orders will be signed by an authorized provider prior to the patient’s discharge from the hospital. The requirement to have delegated inpatient orders signed prior to discharge has been challenging to successfully implement for facilities around the country, especially for short stays. Process choices have included close tracking with e-mail or other reminder notifications, hard stops on D/C orders or actual discharges, and back-end rebilling for IP stays that do not meet this requirement.

It may be helpful for Hospitalists to view the 2MN rule and the inpatient order requirements as a payment policy as opposed to one which defines the care provided to the patient. CMS and its contractors are not making judgments about the need for or the quality of care provided to Medicare Beneficiaries. They are defining the parameters under which they will pay for this care. Under certain parameters (signed admission order and greater than 2MN stay or one of the exceptions), the care will be paid under Part A, as a DRG. Failing these parameters, the care will be paid through Medicare Part B as an outpatient hospitalization.

ROLE OF UTILIZATION REVIEW

Getting the patient status correct is not always obvious, and it is a single action (the admission order) embedded in a very busy sequence of evaluating and starting the course of care for a new hospitalized patient. Most facilities have a team of nurse reviewers who are looking at the admission information, and helping the admitting team make this decision. These professionals, generally named UR nurses, have the training and expertise to understand the nuances of admission status for all payers. Some facilities have divided Case Management and UR, while other facilities may have the same team members performing both of these tasks. UR teams have been trained to use screening criteria such as Milliman or InterQual to determine if a patient meets inpatient or observation status. These criteria are based in medical literature, but also are clear that they are guidelines, and are not meant to overrule the provider’s medical judgment. Interestingly, the Medicare Conditions of Participation (COP) require that facilities employ some type of screening criteria, but do not designate which one. With the implementation of the 2MN rule, the use of screening criteria became essentially moot for Medicare patients, as they now defined inpatient in terms of hospital care and time, not intensity of service and severity of illness. However, the COP for UR did not change, and screening criteria are still required. In addition, many commercial payers, and some state Medicaids still rely on these screening criteria to determine inpatient versus outpatient status.

The interaction of the hospitalist with the UR nurses often involves a conversation around the expected length of stay of a Medicare patient on hospital day two. If the patient has an order for observation, and it appears the patient will stay an additional MN, the UR nurse will suggest that the patient have an IP order written. If the patient has an IP order, and it appears that the patient will be discharged, the UR nurse will discuss whether or not the status should be down-graded to Observation, which will require a process called condition-code 44 (CC44). Any of these interactions may involve an additional physician for secondary review (usually the physician director of CM/UR), particularly if the hospitalist does not respond, or is not moving in the direction that seems appropriate to the UR nurse.

Because the downgrading of a Medicare patient from inpatient status to outpatient status involves potential increased financial impact for the beneficiary, CMS requires that the facility follow certain specific steps if they change a patient from IP to OP (observation) while the patient is still hospitalized. This process is called CC44. The basic steps include notifying the patient, and providing financial counseling, in addition to actually changing the order. Upgrading status from Observation to Inpatient only requires the written order.

The 2014 IPPS final rule also allowed facilities to change the billing status of inpatient hospital stays which are internally audited, as long as the billing change occurs within 1 year of the date of service (timely filing). This regulatory change allowed facilities to put in place back-end review processes for 1MN inpatient stays and decide whether to leave the billing under Part A (DRG) or change the billing to Part B, if the documented care did not fulfill the 2MN expectation/benchmark. Facilities must follow the Utilization Review Conditions of Participation, which require notification of the patient and the attending provider within 2 days of the decision to change the billing from IP (Part A) to OP (Part B). The primary reason to change the billing status to Part B is that the patient received care in the facility for only 1MN, there was a signed inpatient order, but there was no documentation to support that 2MN of medically necessary hospital care was expected at the time of admission.

INPATIENT DOCUMENTATION OF CARE: NUTS AND BOLTS

Adding to the confusion created by an onslaught of regulatory changes is the multitude of payers and their differing rules for status decisions and payment. Clinicians could spend all of their time thinking about these issues, and lose sight of the patient and their care. For inpatient hospital care, the documentation requirements include a history and physical exam (admission note), daily progress notes and a discharge day note. These notes are used for professional billing. For the hospital to bill for the inpatient care, a signed inpatient admission order is also required, as well as a discharge summary.

The best documentation of hospital care tells the patient’s story, and the provider’s plan for care. There are three levels of services for initial hospital care, CPT codes 99221, 99222, and 99223.

The only significant difference in documentation requirements between the three service levels is the medical decision making (Table 31-1). While the lowest admission service may be billed with a lower level history and examination, in general, when a patient is sick enough to require inpatient admission, there is usually medical necessity to document a comprehensive history and physical examination. In order to demonstrate the medical decision making and cognitive work performed, any personal work should be documented, including personal review of ECGs, x-rays, or other tests, conversations with consultants, pertinent history obtained from family members, and any review and summary of old records. This work is counted in the “data” section of medical decision making, along with tests ordered and reviewed. Risk to the patient may be indicated by presenting problems, the diagnostic procedures ordered, or management options selected. The risk table which most coders and auditors use as a reference does not include all disease processes, so the documentation of risk to the patient, whether through literature references (eg, high PESI or PSI scores) or your expert opinion is a reasonable part of the admission and subsequent hospital day documentation. Notations such as “stable on pressors” can be misinterpreted by nonclinical personnel. The admission note should include all of the patient’s problems which are being addressed or treated, including chronic medical conditions, if prescribing chronic medications, or the condition affects the patient’s current reason for hospitalization, include it in the assessment.

The authors favor problem-based notes, following the pattern of: problem, attribution, and plan. Each problem should include the provider’s clinical reasoning or a differential diagnosis (attribution), and some indication of the patient’s short-term risks and severity of illness. What makes this particular patient need to be in the hospital? Why is this illness particularly risky for this patient? The proposed plan of care with an expectation of length of stay should be stated outright, or implied. Instead of stating “IV cefepime,” include an expected length of treatment: “IV cefepime for 2 to 3 days, or until afebrile for 24 hours.” When cosigning or attesting after residents, students or advanced practice clinicians, the responsible physician should include additional information to augment the documentation, particularly if these providers downplay the severity of a patient’s presentation, or do not have the knowledge or experience to recognize the significance of certain clinical scenarios.

Daily progress notes should include all of the problems from the admission note until resolved, and any new problems. Hospitalists should be aware of information carried forward via a macro to be sure that the documentation is accurate and makes sense for the date of service. Resolved problems should be deleted (eg, that hypokalemia from 3 days ago, now resolved). Daily progress notes which include pages of radiographic and laboratory data from the past week will often be ignored by a reader due to their prohibitive length. Consider referring to laboratory test and x-rays as ordered or reviewed and only include pertinent details in your notes. Linking your orders with a statement in your notes “see my orders for any additional plans,” also adds all of your orders to the daily plan and medical decision making.

A “quality” note generally has the following attributes: concise, clear, current, organized, prioritized, and trustworthy. If a Medicare patient is discharged earlier than expected, especially after 1MN of care, the provider should include a statement in the discharge day note or discharge summary outlining the clinical course and unexpected recovery, if this occurred. Again, the goal is to tell the patient’s story: this patient looked very ill when they arrived; we expected 2 to 3 days of IV antibiotics so we wrote an IP order, but they recovered more quickly than we expected, and we were able to send them home after 1MN of outstanding care.

Inpatient facility billing requires a discharge summary (both Medicare Conditions of Participation, and most accreditation bodies such as The Joint Commission), and it is a useful tool for summarizing the story of a patient’s hospitalization. Professional billing allows for a discharge day note (99238, 99239) which is time based. The documentation requirements are slightly different, but it is simple to combine these two documents into a single note, saving time and duplication of effort. Both require a discussion of the hospital stay, discharge instructions including medications and plans for follow-up, as well as the attending provider’s signature. The discharge day note requires a face-to-face service from the billing provider, a final examination, and some notation of time spent. The Joint Commission standards also include procedures and treatments provided and the patient’s discharge condition. The authors suggest that hospitalists discuss the expectations of the discharge summary with their facility, and work to make a discharge day template which includes all of the required elements for both the professional day of discharge service and the discharge summary into a single note. To prevent scrutiny of the discharge day service payment, the documentation needs to clearly reflect that a face-to-face visit occurred on discharge day. If residents are documenting this service, then only the billing provider’s time can be counted toward the discharge day time. Mid-level provider time may be combined with attending MD time and billed as a split-shared service. This time may be discontinuous, and you can count time that is spent in the days prior to discharge, as long as you only “count” this time once. And, if your partner spends time on discharge on Sunday, and you are the actual discharging provider on Monday, then your partner’s time is combined with your time, and all billed together on Monday, as there can only be a single discharge day service billed per hospitalization. If no documentation of time is included in the discharge day note, then 99238 will be billed. In order for 99239 to be billed, the provider must document that he or she spent greater than 30 minutes coordinating the patient’s discharge.

Observation documentation of care

Observation documentation requires an admission note (initial observation services 99218-20), updates in the patient’s clinical condition at some appropriate interval by providers or nursing staff, and a discharge note (observation care discharge, 99217). If the observation services occur within a single calendar day, the services must span greater than 8 hours to be billed to Medicare as the combined observation admission/discharge on the same date (99234-36). Documentation that reflects less than 8 hours of observation services on a calendar date may only be billed as initial observation services (99218-20) with the reimbursement for the discharge work bundled into that payment for Medicare billing; however, this 8-hour rule for observation billing does not necessarily apply to private insurance providers. These time-based requirements may vary among private payers and Medicaid. There is no requirement for a discharge summary in order for the facility to bill observation services. The decision to require a discharge summary for observation stays should be local and facility-based, and is often related to having a concise summary of the patient’s hospitalization. The basic documentation requirements for initial observation care are identical to those for initial inpatient care (Table 31-1). In order for the facility to bill for observation services, an order for observation is also required.

The uncertain future (a last minute update)

CMS has issued the Calendar Year 2016 Outpatient Prospective Payment (OPPS) Proposed Rule (CMS-1633-P) which adds another wrinkle to the payment of short stay inpatient hospital services. The proposed changes include allowing for Part A payment on a case by case basis based on the judgment of the admitting physician, despite the expectation of less than 2MN stay at the time of admission. In addition, the task of reviewing short hospital stays will now fall to the Quality Improvement Organizations (QIOs) with referral to the Recovery Audit Contractors for facilities that have “high” error rates. The details of the review process have not yet been defined at this time. The CY16 OPPS Final Rule will be published around November 1, 2015 for implementation on January 1, 2016.

CONCLUSION

Documentation of a patient’s hospital care has become increasingly complex as the regulations surrounding facility billing for inpatient and observation care have changed, and continue to evolve. Every year, the Center for Medicare and Medicaid Services publishes new rules which alter the billing regulations for both professional and facility services. Commercial payers may have slightly different interpretations. All of these services use provider’s notes and orders to explain and justify the medical necessity for the services rendered. Some knowledge of these billing regulations will allow the hospitalist to comprehensively document the patient’s story and the provider’s medical decision making, while decreasing the back-end work and queries. The classic admission note, daily progress notes and discharge summary that we all learned in medical school are still the backbone of hospital documentation.

SUGGESTED READINGS

INTRODUCTION

The transition from ICD-9 to ICD-10 and to future ICD revisions is challenging but also provides unique opportunities to improve health care and disease/procedure tracking and data. This transition will better support current technology and health care reform initiatives including the Centers for Medicare & Medicaid Services (CMS) value-based purchasing and pay-for-performance programs; coordinated care models such as accountable care organizations and patient-centered medical homes; the government’s Physician Quality Reporting System; and the move toward adoption of electronic health record systems. In addition, it affords great potential to decrease audit risk since ICD-10 codes allow the physician’s documentation to be translated into a more accurate clinical picture, thereby reducing the chance of misinterpretation by third parties, auditors (eg, recovery audit contractors—RAC), and attorneys.

With improved specificity, ICD-10 codes help health care providers submit highly specific codes for the care they provide, and better reflect severity of illness and support medical necessity. This will hopefully reflect in a physician’s profiling on national registries, consumer health sites, and also with health care entity’s quality reporting.

HISTORY

Classifying illnesses to document disease prevalence and causes of death is not a new concept. The first attempts were made as far back as the 1600s. Initially, it was nothing more than a crude and inconsistent nomenclature with little reliable data. However, during the 1800s, an earnest effort began to create a uniformed system. Medical statisticians were commissioned to embark upon this enormous task. They began their work by using the Bertillion Classification of Causes of Death developed by the French statistician, Jacques Bertillion.

In 1893, the first international classification of diseases (ICD) was adopted by the International Statistical Institute. The United States did not utilize a formal disease classification system until 1898, when the American Public Health Association recommended all of North America adopt this system, and recommended it be updated every 10 years.

Each revision made the ICD more detailed. In 1948, the World Health Organization assumed responsibility for the ICD and published the sixth version, which incorporated morbidity for the first time. At this time, they decided to make ICD the official means of collecting international data for epidemiological surveillance and for health management. The WHO Nomenclature Regulations, adopted in 1967, stipulated that Member States use the most current ICD revision for mortality and morbidity statistics. In 1979, the United States adopted ICD-9, and in 1983 the Inpatient Prospective Payment System in the US required ICD-9 codes to be linked to diagnosis related groups (DRGs) for reimbursement. ICD-9 quickly became antiquated, running out of room for new codes for new diseases and new technology. The 43rd World Health Assembly endorsed ICD-10 in May 1990, however, the United States did not adopt it until October 1, 2015. ICD-10 is dramatically more robust and allows for many more codes than any previous edition, including ICD-9 which has been used in the United States since 1979 (Table 32-1). The 11th revision process is underway and the final ICD-11 will be released in 2017.

BENEFITS AND USES OF ICD

• The ICD is the global health information standard for codes to allow comparison of mortality and morbidity statistics. This system helps to monitor death and disease rates worldwide and measure progress toward the Millennium Development Goals.

• About 70% of the world’s health expenditures (USD 3.5 billion) are allocated using ICD for reimbursement and resource allocation.

• It is the diagnostic classification standard for all clinical and research purposes. These include monitoring of the incidence and prevalence of diseases, observing reimbursements and resource allocation trends, and keeping track of safety and quality guidelines. It allows the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease.

The United States was one of the last industrialized nations to adopt ICD-10. They actually use considerably more codes, about 90,000 of those in ICD-10, than most other nations. They use ICD-10 codes in the outpatient setting, and are one of the few countries that use ICD codes for billing. These factors played a major role in the huge monetary investment health care entities made in switching from ICD-9 to ICD-10, and are speculated to have led to the numerous delays in implementation.

WHY DOES ICD-10 HAVE SO MANY UNUSUAL CODES?

ICD was developed to track diseases and procedures for morbidity and mortality data, not for billing. Many ICD-10 codes are quoted as unusual, however were present in ICD-9, just less specific and rarely used (Table 32-2). An example is the ICD-10 code X52.XXXA which is “prolonged stay in weightlessness environment.” ICD-9 has the code E928.0 which is “effects of weightlessness in spacecraft.”

Another point that comes up when comparing ICD-10 to ICD-9 is that ICD-10 has codes for initial and subsequent encounters. It is often asked, “do we really need a code for ‘getting hit by a spacecraft’ the first time and then another code for ‘getting hit by a spacecraft’ a second time?” The “initial” and “subsequent” terms actually refer to the care the provider gives, not the condition itself. So, the first encounter with this patient would code to T75.82XA and any additional encounters with the provider for this same condition would code to T75.82XD.

There are not yet ICD-10 codes for “injured while texting,” or “distracted by cell phone while driving.” However, with the ability ICD-10 has to expand, one would expect such codes to be added soon.

SOME CLINICALLY NOTABLE CHANGES IN ICD-10

• Acute MI codes changed from 8 weeks duration to <4 weeks (28 days) duration.

• New terminology for asthma from worldallergy.org.

• Additional codes need to be used to identify resistance to antimicrobial drugs (Z16-), whenever infection with resistance is documented (V09 was used for all in ICD-9).

• A new code Z91.120- was created for “under dosing due to financial hardships.”

• Injuries grouped by body part, rather than category of injury (eg, femur fracture will be under femur rather than fracture).

• Three different categories for pathologic fractures (due to neoplastic disease, due to osteonecrosis, and due to other specified disease).

ICD-10 IMPACT ON SOME COMMON HOSPITAL DIAGNOSES

HYPERTENSION

• Some of the specificity of hypertension has been eliminated—there is only one code (I10) for benign, accelerated, malignant, hypertensive urgency, hypertensive emergency, and hypertensive crisis. Despite lumping of these hypertension types, it is still important to describe hypertension completely to show severity of illness.

• There are still different specific hypertension codes if it is secondary to heart (I11), kidney (I15), or both diseases combined (I13).

ACUTE RENAL FAILURE

• Documenting Acute Renal Insufficiency and “prerenal azotemia” are vague and nonspecific and usually result in incorrect coding.

• ARF and AKI both code to N17.9 and is a CC.

• ATN codes to N17.0 and is a MCC, “vasomotor nephropathy” and “toxic nephropathy” also code to ATN (N17.0).

SEPSIS

• ICD-10 does not offer much clarification regarding the use of the diagnosis sepsis.

• Sepsis replaces the term “septicemia” that was used in ICD-9.

• SIRS diagnosis use has changed from a coding standpoint—only use for noninfectious origin (eg, DKA, trauma, burn) SIRS w/ organ dysfunction (R65.11) and SIRS if w/o organ dysfunction (R65.10).

• If SIRS leads to an infection resulting in “sepsis” or “severe sepsis,” sepsis supersedes SIRS. So, a noninfectious SIRS leading to an infection resulting in severe sepsis is coded as “severe sepsis” (R65.2-), not SIRS (R65.1-).

• Sepsis must be specifically diagnosed under ICD-10 coding since there is not a code for “SIRS due to infection” as there is in ICD-9.

CLINICAL IMPORTANCE OF ICD-10 TO MS-DRG SELECTION

Clinical documentation is paramount to code selection not only for the provider’s professional fee, but also for the hospital’s MS-DRG reimbursement. The medical record must clearly document the primary diagnosis, and each actively managed condition, contributing comorbidity, and differential diagnosis to the highest specificity known.

DEFINITIONS

Medical Severity Diagnosis Related Groups (MS-DRG) is a classification system that bases hospital reimbursement for inpatient admissions on similar resource use for the identified principal diagnosis and contributing complications or comorbidities. The majority of principal admitting diagnoses have three levels of reimbursement based on the presence or absence of complications or comorbidities (CC) or major complications or comorbidities (MCC). Each MS-DRG is assigned a relative weight (RW). Each facility is assigned a base rate (BR) which is the dollar value of a RW of 1. The hospital’s reimbursement for an admission is calculated by multiplying the RW × BR. Thus, the MS-DRG is the key determinant of the hospital’s reimbursement for an admission.

Complications or comorbidities (CC) and major complications and comorbidities (MCC) are conditions known to increase necessary resources and length of stay (LOS) for a given primary admitting diagnosis. This translates into increased hospital reimbursement when they are present. A list of CCs and MCCs can be found at the CMS website: https://www.cms.gov/icd10manual/fullcode_cms/P0370.html.

KEY PRINCIPLES OF DOCUMENTATION

The selection of MS-DRG’s is based entirely on ICD-10 combinations. The ICD-10 codes are chosen based on documentation in the medical record. Although a more specific diagnosis may actually exist clinically, without adequate documentation to alert a coder or auditor of its presence, the optimal code cannot be submitted.

Three key features of ideal documentation necessary to empower optimal hospital reimbursement are:

1. Clear identification of the primary diagnosis whenever possible. The patient’s physician, is in the best position to determine the principal and secondary diagnoses. Coders and auditors who review the medical record at a later time may never appreciate the clinical picture as well as the provider. Thus, it is crucial for the provider to document their medical judgment regarding all aspects of care, including principal diagnosis. The usual scenario is that ancillary documentation will support these statements, and even make it possible for a coder to come to the same conclusion as the provider; however, sometimes that is not the case. Often there may be more than one diagnosis responsible for the admission. In this circumstance, ICD rules allow for the provider or the coder to select the principal diagnosis that is most beneficial for reimbursement, but that selection must be supported by documentation in the chart. For example, if a patient is admitted with both a COPD and CHF exacerbation without any other conditions that qualify as a CC or MCC, the provider can choose to list COPD exacerbation as the principal diagnosis with acute on chronic LV systolic dysfunction as the secondary diagnosis, which reimburses higher than if the acute on chronic LV systolic dysfunction was listed as principal with COPD exacerbation as secondary.

   COPD exacerbation with acute on chronic LV systolic CHF as an MCC, maps to MS-DRG 190 with a RW = 1.1743 ($5000 × 1.1743 = $5871.50). Acute on chronic LV CHF with COPD, only a CC, maps to MS-DRG 292 with a RW = 0.9824 ($5000 × 0.9824 = $ 4912.00). Assuming a BR ∼ $5000, failing to correctly label principal and secondary diagnoses would result in ∼$1000 lost revenue for the institution.

   Notice that if the patient had a metabolic encephalopathy from concurrent hyponatremia, this is an MCC. Now listing acute on chronic LV systolic CHF as the principal diagnosis with metabolic encephalopathy as a MCC, mapping to MS-DRG 291 (RW = 1.5097, ∼$7,548.50) will reimburse higher than COPD exacerbation with an MCC, MS-DRG 190 (RW = 1.1743, $5871.50). If a patient has more than one MCC, no additional reimbursement is given. It also does not matter which condition is counted as the MCC.

2. Documentation should reflect the highest level of specificity. In the example above, if COPD exacerbation is the principal diagnosis but only “CHF” is listed in the chart without further specifying it as “acute on chronic,” this is a nonspecific term which does not count as either a CC or MCC; the MS-DRG would now change to COPD without MCC/CC, which is MS-DRG 192 (RW = 0.7190, $3595), and result in a $2276 loss in deserved hospital revenue.

3. Complete differential diagnosis and listing of correctly labeled comorbid conditions. Many patients with COPD exacerbations are found to have hyponatremia. A significant number of these present with an altered mental status from the hyponatremia, also called metabolic encephalopathy. However, often neither a comment about the sodium, nor mention of a metabolic encephalopathy ever enters the chart clinical documentation by the clinician within the history and physical or progress notes. With lack of any comment on comorbid conditions, COPD, MS-DRG 192 would only reimburse $3595. With hyponatremia listed, a CC, the MS-DRG would change to 191, reimbursing at $4685, and finally with the documentation of metabolic encephalopathy, a MCC, the MS-DRG would change to 192, worth $5871.50.

   The medical record should always represent the patient’s true complete medical status. These examples are meant to illustrate common documentation pitfalls resulting in unnecessary revenue loss, but should not be misconstrued or used to falsify the clinical picture to “up-code.”

SUMMARY

The transition from ICD-9 to ICD-10 presents challenges to clinicians and hospitals, but also offers unique opportunities to improve health care and disease/procedure tracking and data. A few notable possible benefits of ICD-10 include:

• Addressing technology and health care reform initiatives—CMS value-based purchasing, pay-for-performance programs; coordinated care models such as accountable care organizations and patient-centered medical homes; the government’s Physician Quality Reporting System; and the move toward adoption of electronic health record systems.

• Decreasing audit risk—ICD-10 codes allow the physician’s documentation to be translated into a more accurate clinical picture, thereby reducing the chance of misinterpretation by third parties, auditors (eg, recovery audit contractor—RAC), and attorneys.

• Improving care from improved disease tracking—ICD-10 codes will generate more detailed health care data and a greater flow of that data to improve medical communication, which can potentially lead to advances in disease management and clinical pathways.

• Improve accurate reimbursement—ICD-10 codes help health care providers submit highly specific codes for the care they provide.

• Better determine severity of illness and prove medical necessity—ICD-10 codes better describe the extent and comorbidities involved in a patient’s illness, which in turn facilitates validation of a patient’s condition in support of utilization of goods, services and complex procedures. Correct utilization of ICD-10 should translate into more accurate severity of illness and risk of mortality for patients, resulting in a likely more accurate reflection of a physician’s profiling on national registries, on consumer health sites and with health care entity’s quality reporting.

As of October 1, 2015, the ICD-10 coding classification became the new baseline for clinical data, clinical documentation, claims processing, and public health reporting in the United States. While the outcomes and potential benefits (or risks) of transition to ICD-10 remain to be realized, hospitalists and all clinicians will need to practice within this new documentation environment to optimize clinical care and the accurate representation of patients’ diseases and clinical conditions.

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