Attending Telephone Consults, Advanced Practitioner Consults

September 23, 2014

Get coding guidance on resident consultation via telephone; discharging patients; antepartum care; and more.

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."

Advanced Practitioner Consults

Q: I have a question about our NP seeing and dictating most of the consults done on patients in the hospital. I know "incident-to" doesn't apply to inpatients and Medicare patients, but I know that I can bill the NP as the rendering and billing provider. How should this situation be billed for insurers that don't credential NPs? I think the physician may see these patients in addition to the NP, but there is absolutely no documentation confirming this, other than a cosigning of the NP's notes. Am I missing something?

A: A completely different standard applies in the hospital. It's called "split/shared" or collaborative services. Medicare is quite clear that consults could not be done this way. Even if you use the 9221-99223 series to represent these services, you are still running a risk if you are billing for what amounts to consultative services done by a NP or PA. Consults are supposed to be done by the physician if they are billed in the physician's name, especially if the plan does not credential advanced practitioners.

There's probably a little more latitude on follow ups, but even there the standard is that the physician personally performs some of the work and it is documented. It is not the same standard as "incident-to." The requirements for physician participation are higher although not clearly articulated. Sounds like you have an issue here.

Assessment and Plan Documentation

Q: One of our providers says it is not good enough to just have a problem listed under the assessment portion of the chart. She is citing her labs in the assessment and plan (A/P) portion of the note as well as documenting them under the previous test section. Does she need to do this?

A: There is some value to this approach but it may be a bit excessive. If your provider adds meaningful lab results in the A/P area related to a specific problem that is one way to indicate the status of a problem. But Medicare would likely rather see the English version (words), rather than the clinical values. The best way to document the assessment and plan is to show the problem (diagnosis), the status (stable, improving, worsening, mildly exacerbated, etc.), and in the plan, the prescription, or treatment. Maybe mention a lab value if it underscores or indicates the severity of a given problem, but otherwise, I'd leave the lab section of the chart where it is.

Antepartum Care

Q: Can you provide some guidance on the proper coding for antepartum care?

A: It's likely that there are some elements of this question that I will not address, but here is a general answer. The definition of antepartum care in the maternity and delivery section of CPT states, "Antepartum care includes the initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks, biweekly visits to 36 weeks gestation, and weekly visits until delivery. All other visits within this time period should be coded separately."

Note that the AMA has actually calculated that between 12 and 13 visits are included. These are the antepartum services that are considered part of the maternity global package. And remember, this number pertains to "uncomplicated maternity cases."

There are other codes for providers who do not end up providing delivery services: 59425 for four to six visits; and 59426 for seven or more visits. A parenthetical note directs coders to use E&M codes when only one to three visits occur.

A common point of contention is that the AMA definition states that the initial visit is included - and many providers take exception to this (see http://bit.ly/Antepartum-care for a discussion regarding whether the initial visit should be included).

Another commonly cited issue is the AMA's statement that "all other visits within this time period should be coded separately," is frequently ignored by insurers.

Make sure you know what the particular insurer's definition of the global package is, not just the AMA's definition. If you have a contract with an insurer, chances are that the insurer's definition applies.

HCPCS Level II Codes for Supplies

Q: In a recent edition you mentioned "over and above" in relation to supplies. Does that mean a new wound dressing for a burn or abscess, etc.? What about a spacer given to an asthma patient?

A: As mentioned in that previous article (in the November/December journal), when describing code 99070, the CPT references "supplies and materials provided over and above those usually included in the office visit or service." What you want to report are the HCPCS Level II codes for supplies.

Your specific questions do have codes associated, as in the examples below:

• A4461: surgical dressing holder, non-reusable, each;

• A4463: surgical dressing holder, reusable, each;

• A6021: collagen dressing, sterile, pad size 16 square inches or less, each;

• A4627: spacer, bag, or reservoir, with or without mask, for use with metered dose inhaler;

• S8097: asthma kit (including but not limited to portable peak expiratory flow meter, instructional video, brochure, and/or spacer; and

• S8100: holding chamber or spacer for use with an inhaler or nebulizer, without mask.

These are only a few of the codes that apply. Make sure you have either the HCPCS manual or a program that will let you find supplies. Many may be bundled by the payer, but you need to bill for your services and supplies.

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.

This article originally appeared in the September 2014 issue of Physicians Practice.