Medicare Compliance & Reimbursement

3 simple rules for getting inpatient visits right.

Even the carriers are confused about the rules for inpatient hospital visits. So what chance do you have of handling them correctly?

Not to worry, say experts. Simply remember these simple ground rules:

1) When two physicians are co-managing a patient, they should both bill subsequent visits unless one of them meets all the consult requirements. Keep in mind that the rules for a consult are quite stringent, notes Karen Jeghers, manager of Compliant Billing Services in Carver, MA. The admitting physician must ask for the consulting physician's opinion, the consulting physician must send a note back and the consulting physician must not take over the patient's care.

If your doctor isn't the admitting physician but also doesn't follow the above rules, then you should bill for a subsequent visit. Payers may deny these claims on the grounds that the patient didn't need multiple visits, but with a specialist and a primary care physician, or two specialists, "you can usually show there's medical necessity," notes Jeghers.

For subsequent care, however, the physician has to show that he's reviewed the patient's records, test results and status since the last assessment, notes Jim Hugh, executive vice president at American Medical Accounting and Consulting in Atlanta. For a low-level inpatient follow-up (99231) this could be a simple history, a problem-focused exam and low-complexity medical decision-making, he notes.

2) 11:45 PM and 12:03 AM may be different dates, but they're still the same episode. Although the episode spans two separate days, it's still a single event, says Hugh. If you try to bill separately for an ED visit before midnight and an admission after midnight, "that dog wouldn't hunt in anybody's book."

3) Specialists can admit patients as long as they take full responsibility for the patient. In a late 2003 bulletin, HealthNow NY states that specialists are incorrectly billing for initial hospital visits. "If you are a specialist who has been requested to see a patient in the hospital setting, and this is your first encounter with that patient for that hospital stay," then the service is probably a consultation, HealthNow states. "If you are managing only one body system, and there is an attending physician overseeing the remainder of the patient's care, that provider would bill the initial hospital admission."

But specialists can bill for the initial visit as long as they oversee all of a patient's inpatient care, says Mike Misko, a consultant with Practice Masters in Johnstown, PA. For example, a cardiologist can admit a patient for a particular problem and take responsibility for all of the patient's care. If another problem comes up, the cardiologist can generate an inpatient consult request to another physician.

Hugh tells the radiation oncologists he works with not to be the admitting doctors: "Why would you want to take over the care of the patient?" Medicare bundles the initial hospital visit into many brachytherapy procedures, so the radiation oncologist can't bill for the visit anyway. If the specialist allows the primary doctor to admit the patient, then both doctors can bill separately and the primary care doctor can be responsible for the patient's overall well-being.

If there are two physicians co-managing a patient, one of them still has to be listed as the admitting physician and bill for the initial visit. "You would never have multiple admitting physicians," says Misko. You may have to "arm wrestle" to identify this person, he quips.

There are many instances in which a patient might need two or more physicians to co-manage her care, notes Bob Burleigh, a consultant with Brandywine Healthcare Services in Malvern, PA. A patient may have cardiac and diabetic disorders, requiring an internist or cardiologist and an internist or endocrinologist. A surgical patient may also require a cardiologist, nephrologist or infectious diseases specialist. And a trauma patient may require the concurrent services of a surgeon, neurosurgeon, neurologist and orthopedist on the day of admission and afterwards.