Attending Telephone Consults
Q: I am trying to determine whether there is a regulation that prevents or allows an ENT (a volunteer instructor in a GME program) to bill for consultation with a resident over the telephone? The resident examined the patient and discussed the findings with the volunteer teaching physician (over the phone). The teaching physician did not examine or have face-to-face contact with the patient, and he signed the record the next day.
I reviewed the guidelines for teaching physicians, interns, and residents, and the Medicare Claims Processing Manual, specifically the primary-care exception, and I didn't find a direct answer. Any help would be appreciated.
A: This is a pretty big "no" regarding whether the ENT can bill for the consultation. The whole premise behind an attending billing for his supervision and training hinges on his presence in the clinic. If you look at any of the attestations, you'll see that they cover "my exam" or "with the resident." For the primary-care exception, it states the attending must be present in the clinic. I'd look at those regulations again — presence is all over them.
Discharged Patient Confusion
Q: I have a couple of questions involving hospitalists:
Question 1: Doctor A is the overnight call hospitalist who admits the patient to Doctor B (same group and same Tax ID number) at 12:05 a.m. Doctor B. follows up with the patient during the daytime on the same calendar day. Can Doctor B post a charge?
Question 2: Doctor A discharges the patient today and provides documentation to support a discharge CPT code. However, the patient does not leave the hospital for logistical reasons and Doctor B, who is covering for Doctor A, sees the patient the next day. Doctor B discharges the patient and this time the patient leaves the hospital. Who bills for the discharge, Doctor A or Doctor B? Only one discharge code will be paid obviously.
A: Let's start with Question 1. If Doctor A did not come in and see the patient, Doctor B gets the admit. If Doctor A did come in and see the patient, Doctor B could conceivably bill prolonged services in addition to Doctor A's admit, but this is very messy with two docs involved. And, most groups aren't very good at managing this well. I'd suggest you avoid using prolonged services.
Really, the admits and the follow-up inpatient codes are daily charges and should reflect the combined work of both providers. You should really only have one charge per day except for critical-care events and procedures. It is common for groups to want to use the code as an RVU counter and productivity measure, but it doesn't work well in this setting.
In regard to your second question, one issue here is that the discharge code 99238/99239/99217 should not precede a follow-up code as the follow-up charge will likely be denied. If Doctor A does a 99238 on day one, it will likely also support a 99231, maybe more. The safer play is not to bill a discharge code until the next day when you know the patient is gone.
Often, when a patient fails to leave on day one, it is due to logistics, and the physician on day two has very little to do relative to medical management. If that is the case, let Doctor A bill his discharge as planned, and Doctor B won't miss out on much. This should be a situation where "it all evens out in the end."