Gastroenterology Coding Alert

Avoid making the same mistakes these doctors made.

You see a patient in the hospital and perform her initial workup, then report the appropriate E/M code. Easy, right? Not exactly. According to Medicare’s most recent error rate data, gastroenterologists have the absolute highest improper payment rate for initial hospital visits.

Background: CMS issued its “Appendices for the Medicare Fee-for-Service 2016 Improper Payments Report” in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 11.7 percent improper payment rate among Part B claims during 2016, with the majority of those being classified as overpayments to providers.

Particularly troubling for gastroenterology practices is the 43.7 percent error rate seen among this specialty for initial hospital visits, which totaled $42.8 million in projected improper payments. This was the highest error rate in this category, followed by cardiologists, who had an inpatient E/M error rate of 37 percent.

Overall, gastroenterologists logged an 11.8 percent error rate among Part B claims submissions, which was higher than the national average when all specialties were combined. Among the Part B issues that reviewers noted as being problematic were upper gastrointestinal endoscopy, lab tests, and subsequent hospital visits, but these paled in comparison to that sky-high initial hospital care error rate.

Read on to ensure that your initial hospital visits don’t land you in trouble by following our four expert tips.

Tip 1: The Initial Inpatient Code Is Your Admit Code

A common misconception is that you can find an admit code in your CPT^® manual, but that isn’t the case — the initial inpatient code is what you should use when you admit a patient to the hospital.  

The admitting physician should report a code from the 99221-99223 range for his care if he documents the elements contained within the codes (appropriate history, exam, and medical decision-making). He is not billingfor the admit itself — he’s billing for the care that he provides, based on the documentation.

CPT^®  states that the initial hospital care codes “are used to report the first hospital inpatient encounter with the patient by the admitting physician.” Physicians get paid for the care they provide, not for administrative work — processing the admission, including dictating the required H&P, counts as administrative work, not medical care.

Many insurers will only pay one claim per hospital admission with an initial inpatient code. For instance, the policy for Blue Cross and Blue Shield of Florida says it will pay “for one initial hospital care service per hospital stay per patient. If multiple claims are received with one of the initial hospital care services CPT^® codes, the first claim received will be allowed and the subsequent claim(s) will be denied with instruction to rebill with the appropriate subsequent hospital care code.”

Tip 2: When Multiple Specialists Visit, Look to Modifier AI With Medicare

Because only one physician can charge for a patient’s initial hospital care, you’ll see denials if you report a code from the 99221-99223 series and another specialist does as well. Therefore, Medicare created modifier AI (Principal physician of record) to show which doctor admitted the patient. The other doctors seeing the patient for consultative services will charge for their services with a code from the same series but with no modifier to report his first visit with the patient.

Background: Before 2010, only the admitting physician reported initial hospital care codes, and specialists who saw the patient separately billed inpatient consultation codes. Since CMS no longer recognizes the consultation codes, multiple physicians may report initial hospital care during a patient’s visit.

Medicare doesn’t accept consultation codes but private payers may if the documentation meets consultation coding requirements. If your payer does accept hospital consult codes (99251-99255), those codes may be correct instead of 99221-99223.

Tip 3: Not All Admissions Are Inpatient

Make sure the patient your gastroenterologist attends has been admitted as an inpatient, since not all facility settings qualify as “inpatient” status. Even if the doctor saw the patient in the hospital, the ED [emergency department], for instance, is an outpatient setting, and gastroenterologists frequently provide ED care.

“If the patient is seen in an outpatient setting then for an initial encounter, the gastroenterologist will use a new patient code (99201-99205) and cite the place of service on the claim indicating it was not in the office,” says Michael Weinstein,  MD, president and CEO of Capital Digestive Care in Silver Spring, Md. “Often a gastroenterologist will see a patient in the hospital as an inpatient or one under observation previously seen for known digestive problems. In those cases, the code should be from the subsequent care codes (99231-99233), or if in the emergency department, from the established visit codes (99212-99215),” he says.

Inpatients include patients admitted to hospitals, partial hospital settings, or nursing homes. Your gastroenterolo­gist’s consultations in the ED or for patients admitted to observation status are not considered inpatient services.

4. Readmissions Typically Warrant New Inpatient Period

If the patient is discharged and later readmitted at another time with a new problem, you can typically report a code from the 99221-99223 series again. However, if the rehospitalization does not require a complete reevaluation by your physician but follow-up services are provided, then you should choose from the follow-up hospital visit codes, 99231-99233, instead.

Resource: To read the full CERT document indicating gastroenterologists’ high error rate for inpatient visits, check out the Medicare website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/AppendicesMedicareFee-for-Service2016Im­properPaymentsReport.pdf.