Medicare Compliance & Reimbursement

Question: Our patient has a complex health history, and is therefore under treatment from four different practices simultaneously. Recently she was admitted under observation care for a day. When our practice billed the discharge code, we were denied. We learned that one of the other practices billed for the service first. Should that practice’s provider split the payment with all of us?

Answer: Several physicians might be managing the care of a patient, and all might try to bill for the discharge — but only the attending physician should collect for it, CMS indicates.

MLN Matters article MM5794 notes, “Only the attending physician of record (or physician acting on behalf of the attending physician) shall report the hospital discharge day management service (CPT^® code 99238 or 99239).” Any other physicians should instead report a subsequent hospital care code (99231-99233) for a final visit with the patient.

Keep in mind that sometimes a patient may not be eligible for a discharge code. This can happen in various circumstances, such as if the patient never left the emergency room and thus was never admitted as an inpatient. Also, keep in mind the two-midnight rule. In this case the physicians should report an ED service code (99281-99285).

“See also the AI modifier that identifies the principal physician of record,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, Iowa.