Medicare Compliance & Reimbursement

What the carriers leave out could be as important as what they say.

If you're relying on your carrier's bulletins and FAQs to tell you how to bill for inpatient visits, then you could be courting trouble.

Two recent carrier statements on inpatient visits either leave out crucial information or encourage physicians to bill a higher-paying code when a lower-paying code may be more appropriate, say experts.

In a recent Frequently Asked Questions feature, AdminaStar Federal offered guidance that could be confusing at best. A provider put forward a situation in which a physician sees a patient in the ER and then decides to admit her to the hospital, and asked whether the doctor should bill for the ED visit and initial hospital visit separately.

AdminaStar correctly said all services the doctor provides in conjunction with the hospital admission "are considered part of the initial hospital care when performed on the same date as the admission."

But this statement assumes that the admitting physician is also the Emergency Physician, which rarely happens, notes consultant Bob Burleigh with Brandywine Healthcare Services in Malvern, PA. AdminaStar also fails to address a fairly common scenario: an ED physician and an attending physician both see a patient in the ER before midnight. Then the attending admits the patient to the hospital soon after midnight. Because the date has changed, carrier edits may allow the attending to bill for both the ED visit and the admission, but it's still wrong, Burleigh notes.

Also, the AdminaStar statement may leave physicians with the incorrect impression that an ED physician and an attending can't both bill separately for the services they provided. The carrier's response "will create new confusion, rather than dispel it," he adds.

Also, HealthNow NY published a bulletin in December 2003 stating that medical review staff had seen instances of specialists billing for initial hospital visits, instead of primary care doctors. In some cases, the primary care docs tried unsuccessfully to bill for the initial visit afterward. HealthNow advised the specialists to bill for consults instead.

While HealthNow's statement "makes a rational case" for letting a primary care doctor bill for the initial visit, it ignores the possibility that the primary care doctor and specialist may be co-managing the patient's care, notes Burleigh. In that instance, the specialist may bill for subsequent hospital visits instead of consultations. Medicare pays less for subsequent inpatient visits than for consultations, so HealthNow's advice is effectively encouraging doctors to overbill.