Wiki Outpatient Hospital Visit Documentation

[jcevans]

I am an outpatient hospital coding and compliance specialist who has been tasked with implementing documentation criteria to support billing two facility E/Ms on the same date of service for a given patient.

For example, the patient has a morning visit with a hematology physician and an afternoon visit with a nephrology physician; and my two bills look like the following:

Hematology:
•Professional E/M: 99215
•Hospital E/M: 49999215 – 25

Nephrology:
•Professional E/M: 99213
•Hospital E/M: 49999213 – 27

The hematology physician and the nephrology physician each have their own clinic note posted to our electronic medical record system to support the professional E/M charges.

What additional documentation is necessary to demonstrate the justification for charging a second hospital E/M on the same date of service? (Nursing note, progress note, etc.)

Is the physician's clinic note enough information to justify the Hospital E/Ms to the insurance company?

 

[kevbshields]

Great question.

Part of the issue would depend on any payer policies. Typically (in the Medicare view), physician work plays no bearing on the facility charges or E&M level. Since you mentioned an electronic record, there should be documentation that shows ancillary staff involvement (e.g., taking of vitals, etc). I would incorporate that into my documentation for the facility portion. However, assuming that your physicians' overhead is carried by the hospital, it reasons that their individual notes also support the E&M reported by the facility--in a more distant sense.

If I were the auditor on the payer side verifying the appropriateness of these charges, I would expect to see both the nursing notes and physician notes. If any additional services were provided during the visit, I would expect to see those records as well.

Out of curiosity, why is Modifier -25 appended to the first line item? I do not see additional CPT reported for this, although perhaps you've left off those for some reason.

Thanks!

 

[jcevans]

Thank you Kevbshield for your response.

Modifier 25 was added because there were several lab charges on that particular bill.

One of the problems we are having with the medical record system is the nursing notes (vitals, etc.) often get "streamlined" so the first nursing flowsheet gets used again for the second physician visit. I will see the same nurse's name, two different timestamps, and the same vital information (blood pressure, pulse, etc.). I am concerned this will not be appropriate to demonstrate medical necessity and receive reimbursement for the second facility E/M.

 

[kevbshields]

What you are describing is a valid concern. I'd get with IT to see if that "streaming" functionality could be shut off. Of course, providers have a fit, but truthfully do not worry over these "administrative" obstacles as much as we do.

Good luck to you.