Giving credit for exam work?

Q If an advanced registered nurse practitioner sees a patient for an inpatient consult and dictates: “See H&P notes and labs in chart” in her exam section, then only notes vitals and mental status exam, can I give her credit for work in the exam piece in the H&P when it was completed by another physician?

A Is she billing a consult separate from the other physician? Or are they collaborating on the same day with one charge going out? If it’s the former, and the other doc is using that H&P as part of his or her admit or other bill, then she can’t use it. The work involved in performing the physical exam or any other part of a given visit belongs to that visit and its associated code, charge, and payment.

You can’t “borrow” work that has been previously performed, claimed, and paid for and include it in a new code you are presenting for payment — it’s double dipping.

If it’s the latter case, and these two providers are collaborating with one bill going out, then reference Medicare’s consult guidelines: “Carriers shall instruct physicians and qualified NPPs that a consultation service shall not be performed as a split/shared evaluation and management service.”

Decision making for established visits

Q I have heard that medical decision making should be one of the key components when leveling a subsequent/established patient office visit. I think this is right, but at our institution, we will need something to support this since the documentation rules state two of three key components. Do you have anything in writing to support this?

A Decision making should be one of the key components on established visits. But it isn’t a requirement per se — not in the CPT manual and not in any specific Medicare guidance that I am aware of.

Medicare states that “medical necessity is the over-arching criteria for payment.” The decision-making component — namely how many problems do people have, what is the status of those problems, and what are you going to do about it — is most closely linked to medical necessity which is problem driven.

What you are looking for is not a regulation — it’s just common sense. So, there is no authoritative dictum or guidance that says medical decision making must be one of the two components; it just makes sense that it is. I hope that helps.

Billing a hospital admit

Q I have a question that I have seen answered multiple times differently. When a patient is seen in the office and sent to the hospital with orders, but the physician does not come to the hospital until the next day, can the physician bill for an initial hospital visit on that date? I have seen guidance that the physician needs to be physically present at the hospital on this date to have the face-to-face encounter allowing him to bill for the admission, and then I have read guidance that he can bill even if he didn’t come to the hospital that day. I have read that he could bill for the inpatient admission on the morning he does come in to see the patient and the office visit would be billed the day the patient was admitted.

My problem is I have a physician who comes into the hospital the next morning and backdates an entry for the prior day (office visit day and hospital admit date). He only writes “H&P” for this date, however the H&P is not dictated until the actual day the physician comes to the hospital to see the patient. What is he trying to accomplish by doing this? To me, it is very suspicious and makes me think that he is not allowed to bill for the hospital admission unless he sees the patient face to face in the hospital. Can someone help me with this?

A Anyone who is backdating anything is operating outside the rules. A hospital admission service requires the presence of the physician in the hospital on the day he bills the admit service.

You can go to the hospital and perform your admission services the day you send the patient to the hospital and bill the admit that day. You will not bill the office visit if you do it this way.

You cannot see the patient in the office and send him to the hospital, and bill the admit that day if you didn’t go there. This is often called a “direct admit” and practitioners seem confused about how to do this.

If you don’t go the hospital until the next day, and that is when you perform your initial inpatient service —which is the name of the CPT subcategory the admit codes come from — then you bill the admission codes 99221-99223 with the date of service on the second day. This also allows you to bill the office visit the previous day.

I don’t see what the provider in question has to gain from playing with the dates. If he backdated the admit to the previous day — in addition to essentially fraudulent behavior — he loses the office visit. Good luck.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This article originally appeared in the February 2010 issue of Physicians Practice.