Cardiology Coding Alert

GAO's correct and complete response leaves out 4 factors

The question of how to code a physician transferring a patient from one hospital to another seems simple, but the answer is more involved than you may think.

The Government Accountability Office (GAO) asked CMS call centers this very question and found that 96 percent of the time, the CMS call centers' answers were inaccurate, only partially correct, or totally incomplete.

However, even the GAO's correct responses leave cardiology coders with something to be desired.

The GAO asked: How should you code a physician transferring a patient from one hospital to another?

What the GAO counted as the correct and complete response: "Physicians may bill both the hospital discharge management code and an initial hospital care code when the discharge and admission do not occur on the same day if the transfer is between (1) different hospitals, (2) different facilities under common ownership which do not have merged records, and (3) between the acute care hospital and a PPS-exempt unit with the same hospital when there are no merged records. In all other transfer circumstances, the physician should bill only the appropriate level of subsequent hospital care for the date of transfer."

What's left out: CMS' response mentions nothing about transfers between physicians in the same group practice, hospital care versus consult codes, or place of service. Nor does this response take into account discharges performed by a nonphysician practitioner (NPP) or physician assistant (PA).

1. Group Practice Member Changes Rules

Cardiologists may transfer a patient to another member of their group practice.

According to the Medicare Carriers Manual (MCM), section 15501.1, if a patient undergoes more than one E/M service on the same day by more than one physician in the same group, then "only one E/M service may be reported unless the E/Ms are for unrelated problems." In this scenario, both cardiologists would select the combined E/M level and submit the appropriate code.

Note: If the second physician belongs to the same group practice but is of a different specialty (for example, an internal-medicine specialist transfers the patient to a cardiologist), you should report the E/M codes separately.

2. Cardiologists May Share Visit With NPP

The CPT manual's introduction to codes 99238-99239 says that these "codes are to be used to report the total duration of time spent by a physician for final hospital discharge" - but does that include work provided by nonphysician practitioners?

The term "physician," with regard to E/M services, entails NPPs when they provide services within their scope of practice, licensure, collaboration rules and billing rules for Medicare, says a CMS official. This means that NPPs may report the codes for "hospital discharge, management," and for "initial hospital care."
Keep in mind: A physician may also participate in the E/M service, which means that you can qualify the claim according to the shared-visit rule.

"We do permit the hospital discharge day management service to be split or shared between the physician and the NPP," the CMS official says.

In the hospital facility setting, the physicians must provide some aspect of the E/M service face-to-face with the patient - meaning that you must have both the physician's and the NPP's personal documentation regarding what each did during his portion of the service.

3. Choose Consult or Subsequent Care

The GAO's correct and complete response states, "in all other transfer circumstances, the physician should bill only the appropriate level of subsequent hospital care for the date of transfer." But what happens when the cardiologist admits a patient to hospital A but transfers him to hospital B on the same day, because hospital A does not have a cardiothoracic surgery backup?

In this circumstance, you should only report the applicable initial hospital care code (99221-99223), says Cynthia Swanson, RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb. "The cardiologist is considered the admitting physician at both facilities (A and B)," Swanson says.

You'll want to get that code right because there's an $80 difference between 99223 and 99233 (Subsequent hospital care), based on Medicare national averages.

Suppose a cardiologist provides a consult to the patient in hospital A and subsequently transfers and admits the patient to hospital B. In this case, would you report the consult at the applicable level (for example, 99255) and not the subsequent hospital care code (99233), as stated in the GAO's correct response? That's a $120 difference, based on national averages. Or would you rather report the admission to hospital B? After all, when a doctor provides a consult in the emergency department and admits the patient on the same day, most coding experts say that you should only report the admission.
 
4. Don't Forget Place of Service

The GAO response does not mention the place of service, which can be a problem in transfer situations. Using the previous example, if the consult took place at hospital A and then a transfer occurred to hospital B and you report a consult code (99255), which place of service should you choose - hospital A or hospital B?

Many coding experts vary on their interpretations. For example, "If the consultation was performed at hospital A, you should list the name and address of that facility in the field location 32 of the CMS-1500 claim form," Swanson says. Remember that you have to submit a separate CMS-1500 claim form for the corresponding services that the cardiologist provided at hospital B.

Others coding experts may tell you that if your cardiologist performs a consult in hospital A and admits the patient to hospital B, you should bundle the consult code into the admission code, not the other way around.

Therefore, the GAO's correct and complete response remains far from black-and-white.

Editor's note: To read the full GAO report, go to http://www.gao.gov/new.items/d04669.pdf.