Gastroenterology Coding Alert

Same-day hospital admission may cut the office visit out of the equation

Carriers are scrutinizing your inpatient hospital visits more than ever before. Make sure you're ready.

Problems: Medicare overspent $112 million on claims for subsequent hospital care code 99233 and $41 million on 99232, according to the November 2006 Comprehensive Error Rate Testing report. In both cases, visits were upcoded by one level, CMS says.

Also, Medicare overspent $57 million on upcoded claims for inpatient consult code 99254. And CMS says upcoded claims for initial inpatient care code 99222 cost the program $26 million.

Meanwhile, more than one doctor often tries to bill for initial hospital care (99221-99223) for the same patient, says a bulletin from Healthnow New York's Upstate Medicare Division (UMD). "Only the admitting physician may file a claim for the initial hospital visit," says UMD, which warns that this is a "common source of error."

High error rates with inpatient visits are leading to more scrutiny, says Linda Martien, CPC, CPC-H, coding specialist with National Healing Corp. in Boca Raton, Fla. She and other experts offer these six tips:

1. Don't Confuse 'Admission Orders, Initial Visit'

Many coders think they can bill for an initial inpatient visit just because the doctor performed a history and physical exam in the office before admission. Because he dictated the history and physical for the patient without a face-to-face visit in the hospital, the doctor may think the practice can bill an initial inpatient visit, but this is wrong, says Maxine Lewis, BA, CMM, CPC, CCS-P, with Medical Coding Reimbursement Management in Cincinnati.

For example: An elderly patient presents to the office with abdominal pain, fever, nausea and vomiting that started a few days before the office visit. The gastroenterologist collects a comprehensive history and performs a comprehensive physical examination. He decides the patient is dehydrated and may have diverticulitis.

He decides to admit her to the hospital for intravenous antibiotics, fluids and further testing. In this scenario, you should only report the admission--not the initial office visit beforehand. Note: If the hospital treatment includes surgery, you cannot report the admission.

2. Check the Documentation

Look for the physician progress note or bedside note that shows the physician actually spent time with the patient in the hospital and reconfirmed the key components of the E/M visit performed earlier that day in the office, Martien says.

3. Watch Diagnosis Coding

Problems arise when one patient is in the hospital with multiple problems, Martien says. For example, a patient could be in a car accident and need an orthopedist, neurologist, gastroenterologist and others. Make sure your physician uses diagnosis codes that directly relate to his specialty area, and use modifiers where appropriate, Martien adds.

4. Distinguish Between Observation and Inpatient Admission

Pay attention to the documentation. You may need to follow up with the doctor and even the hospital to verify the patient's admission status, Martien says. A patient's observation status should be noted on the admission note, Lewis says.

5. Educate Your Gastroenterologist

Your gastroenterologists need to know about the proper levels of inpatient service, Lewis adds. If your hospital does not allow templates, your doctor may have a harder time remembering the service-level requirements.

6. Look for Discharge Summary

Gastroenterologists sometimes dictate the discharge summary before the patient's discharge, Lewis says. The physician or another member of the same group may not actually see the patient on the day of discharge, which means you can't bill for the discharge. Instead, the doctor may write a note instructing that if Mrs. S has no fever for 24 hours, she can go home.

A face-to-face service by the physician must occur on the discharge day and be evident in the documentation. Make sure the hospital sends all discharge notes to your office so you can see when the doctor dictated them.

Watch out: Several recent carrier audits have also focused on inpatient critical care services, Lewis says.