Pulmonology 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 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. "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 consultant with National Healthcare Review in Woodland Hills, Calif. She and other experts offer these six tips:

1. Don't confuse "admission orders" with "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.

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 evaluation and management visit performed earlier that day, 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, pulmonologist 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 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, Lewis says.

5. Educate your pulmonologist about the proper levels of inpatient service, Lewis adds. If your hospital does not allow templates, it's harder for your doctor to remember the requirements of the levels of service.

6. Look for discharge summary. Pulmonologists 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.