# Inpatient coding question



## jdibble (Jul 1, 2010)

This question is in regards to billing for face-to-face Prolonged services. My Hospitalists have questioned how they should bill for services as follows:

A patient is admitted in the early hours of the day - 12:00am - 1:00am lets say.  The Hospitalists will see the patient at this time and do the Initial Inpatient visit.  Another Hospitalist (the day shift) will see that patient later in the day, say around 4:00pm for a subsequent visit.  A subsequent visit would not pay as only one E/M per day is billable.  One of my Hospitalits has been using the Prolonged services codes for these visits and says that she believes where she worked before they were paid for these codes.  Medicare is denying this stating that they need the original E/M code.  The Intial visit is billed under another Hospitalists name, but same tax ID.  How would you code this scenario? 

Any thoughts on this would be great!  My Hospitialists are all concerned about how to capture the individual work that they are doing for these patients as they are compensated based on the RVUs they generate!

Thanks,


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## FTessaBartels (Jul 1, 2010)

*Medically necessary & time documented?*

First question - are both physicians in the same specialty and group practice?
Second question - is this "second" visit on the same DOS medically necessary?
Third question - is time documented for the second visit, and is that time 30 minutes or more?

If the answer to ALL questions is YES ...  You *can* use the prolonged service codes. *HOWEVER* ... you will have to bill both the initial hospital visit and the prolonged service code on the same claim and under the same physician name/NPI. We would send the bill out under the name of the physician who did the initial visit. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## to0318 (Jul 1, 2010)

*T. Oxendine, CPC*

So then what you are talking about is bundling, correct?  So then that could also be true of more than one physician billing for an EKG on the same pt on the same DOS.  For instance as the example that jdibble's gave, from a Nocturnist to a morning physician.  I code also for Inpt Hospitalist, and I knew that when a Nocturnist say, admits at a level of IH2 and the morning physician rounds and does an SH3 then I knew that we could up code the IH2 and make it a IH3 to bundle the IH2 & SH3 together, but it never occurred to me about the EKGs, Prolong Care or Critical Care codes.  Something to think about.  My plans is to Specialize now and try for the CEMC so I will be more effecient.

Thanks!


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## mitchellde (Jul 2, 2010)

You are correct in that you add the complexities of the two visits together however I think it is incorrect to automatically assume that this will give a level 3 initial visit.  It MIGHT.  Also you may not automatically be able to assign prolonged care, the correct statement is you MIGHT.  It all depends on the documentation and time must be documented by the physician on both encounters to think about prolonged time.  Just my 2 cents.


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## jdibble (Jul 6, 2010)

Tessa & Debra -

Thanks for your help...

The physicians are the same practice, I believe the same specialty. As far as the Medical necessity part - the Hospitalists state that they are required to see the patients once every 24 hours and if the patient is admitted in the early hours of the morning, they usually do the next visit later that day to get them onto a "normal" visit schedule - rather than waking the patient say at 1:00am for their next visit.  The part about documenting the time - I am working on this issue as the majority of these Hospitalists are not documenting time for anything!

I wasn't sure if it was "legal" to bill services under a physician who did not perform them - so you are saying the insurance and Medicare would not question billing out a visit under another physician? 

Thanks,


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## FTessaBartels (Jul 9, 2010)

*Hospital protocol does NOT equal medical necessity*

Just because the hospital requires that the patient be seen does not mean the visit is *medically necessary*, 

If they are not documenting time you cannot use the prolonged service codes, and Debra's solution of rolling all the work into one level of service is correct.

For billing purposes, physicians of the same specialty in the same group practice are considered the same physician. Your practice should have a policy in place that directs you to either bill all services provided on the same DOS under the first physician or under the last physician - doesn't make any difference which way you go as long as you are consistent. In our practice when 2 doctors see the patient in one day, we bill under the first physician to see a patient on any given DOS.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## jdibble (Jul 12, 2010)

Yes it does Tessa. Thanks. Now I have something to go back to Administration with.  They will need to change their processes somehow to capture these charges under one physician as each Hospitalist inputs their own codes into the system separately and then someone inputs the charges into the billing system - they don't use coders for any of these processes!!!  No wonder they are losing money and everything is so messed up!.


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## abc1099 (Jul 13, 2010)

We just had this discussion yesterday.  We need some guidance....our physician documented she spent one hour with the patient and family and an additional 20 minutes later that same day discusssing the patient with another physician.  We have never billed prolonged servives, so how would we bill this?

Ann Campbell, CPC


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## jdibble (Jul 15, 2010)

Ann - in your situation, I don't think you would be able to bill for prolonged services.  CPT codes 99358 and 99359 are used for prolonged services without direct patient contact, however the time spent must be 30 minutes or over to use.  If the doctor spent most of the visit in counseling, she could use a higher E/M based on time if it documented in the chart the time spent in counseling and what was discussed.  As far as the 20 minutes spent with the other provider, that could be used for points towards your Data reviewed in the MDM.  

This is how I see it - maybe someone might have another suggestion or different answer.


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## abc1099 (Jul 16, 2010)

Yes I agree Jodi.  The more we looked into it we realized that the additional 20 mins would not count.  We are always learning!


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