Document Inspection

The Hospitalist. 2009 November;2009(11):

November 1, 2009|The Hospitalist

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

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

Discharge Day Management

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

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

Reminder: Prolonged Care

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

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

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

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

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

FAQ

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

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

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