Orthopedic Coding Alert

Medicare overspends millions on upcoded inpatient visits

Carriers are scrutinizing your inpatient hospital visits more than ever before. Will you be ready?

Problems: Medicare overspent $112 million on claims for subsequent hospital care code CPT 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 claims.

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

Meanwhile, more than one physician often tries to bill for an initial hospital visit (99221-99223) for the same patient, warns a bulletin from Healthnow New York's Upstate Medicare Division (UMD). -Only the attending physician may file a claim for the initial hospital visit,- says UMD, which says 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 consultant with National Healthcare Review in Woodland Hills, Calif. She and other experts offer these seven tips:

1. Don't confuse -initial visit- with -admission.- Many coders believe they can bill for an initial inpatient visit just because the doctor performed a face-to-face visit with the patient in the hospital on the day the patient was admitted. But if the patient has already been admitted, you should instead select a subsequent hospital care code (99231-99233).

2. Check the documentation. Try to see the physician progress note or bedside note that shows that the physician actually spent time with the patient in the hospital and performed at least some of the key components of the evaluation and management visit, Martien says.

Note: It can be -tedious- to obtain inpatient documentation because the  hospital staff is busy, and sending you information is way down on their to-do  list. But if you forge a good relationship with the hospital staff, you can get the information you need.

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, pulmonary specialist and others. Make sure your physician is using 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 a query to the doctor and even the hospital to verify the patient's admission status, Martien says. The patient's observation status should be noted on the admission note.

5. Make sure inpatient consults are clearly documented. Ensure that the hospital and other providers send all consult notes to your office. Ask the hospital or other physician to mail or fax you any consult documentation that you may be missing.

6. Educate your doctor about the proper levels of inpatient service. Few hospitals allow templates, so it's harder for your doctor to remember the requirements of the levels of service.

7. Look for a discharge summary. Physicians sometimes dictate the discharge summary before the patient's actual discharge. 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. Make sure the hospital sends all discharge notes to your office  so you can see when the doctor dictated them.