Single Note for Admit/Discharge; Confusing HPI Elements

January 9, 2015

Q: When a patient has been admitted and discharged on the same day, can one note support a same day admit/discharge code?

Single Note for Admit/Discharge

Q: When a patient has been admitted and discharged on the same day, but the physician only documents one note that indicates the patient will be discharged, can that one note support a same day admit/discharge code (99234-99236)?

A: The answer is yes. Two separate notes are not required, but that single note must encompass both the components of the admit and the discharge. For instance, the note should include some details of the discharge that would be present in a typical discharge code (99217, 99238, or 99239).

Confusing HPI Elements

Q: We have a dispute in our office over how many elements are in the following HPI:

"Ms. X is a 62-year-old female who is here for an annual visit for her breast cancer. She has a history of Stage II, ER Positive/HER right-sided breast cancer. She was diagnosed 10 years ago and treated with mastectomy and radiation therapy. She finished adjuvant therapy with tamoxifen four years ago." How would you assign the HPI in this case?

A: To begin, the term "annual" is a poor word choice here. The frequency of surveillance may be annual, but the term annual carries a definite overtone of prevention that you don't necessarily want to emphasize here.

I think the most common assignment of HPI elements here would be:

• Breast - Location

• Stage II ER Positive/HER (could be either quality or severity)

• 10 years - Duration

• Mastectomy/radiation and tamoxifen-modifying factors

On the diagnosis coding side, this will have to be coded as a personal history of breast cancer.

Established Versus New

Q: I have a question regarding the medical-decision-making Table A Element: New Problem (to examiner). One of our physicians has been out on medical leave and another physician from the group has been taking on his patients. Should the covering physician consider the patient's established problems new problems? Or are they established to the group practice?

A: The original medical-decision-making tables include no guidance beyond what is stated in the table. The parenthetical note (to examiner) is all we get. As a result, we have to rely on the large body of authoritative guidance to determine the correct approach.

The CPT manual has very specific guidance regarding when a patient can be considered "new" to a physician, and it includes some advice regarding this. It states: "In the instance where a physician is on-call or covering for another physician, the encounter will be classified as it would have been by the physician who is not available."

The same way a patient is considered established if he has been seen by a physician of the same group and same specialty, an established problem or diagnosis should be considered established as well.

If you took the opposite tack (that the table literally means that if a provider has not seen the patient before all problems are new) the table would lose a certain degree of meaning. In reimbursement terms, this might have the effect of increasing an E&M service level, based not on the nature or severity of the problem, but whether the patient's regular doctor is present. That does not sound like a medical-necessity-driven outcome, which is what all government and most commercial payers require.

If you treat the patients as established, even if they are new to the physician, treat the patients' established problems as established as well. Of course, brand new problems are new to everyone.

Supervising Physician Requirements

Q: If a resident or intern provides care in psychiatry or psychology, does the supervising provider actually have to see the patient to bill a CPT and E&M code?

In psychology, we provide individual supervision to discuss each case and then the licensed provider must read the note, attest to the diagnosis and CPT code entered, and sign the note electronically. I have heard from psychiatry colleagues that they cannot bill anything for CPT or E&M codes unless they physically lay eyes on the patient that a resident has treated. Is this correct?

A: Since most residency settings are funded with federal direct medical education monies, the physicians at teaching hospitals guidelines apply to this type of scenario. These guidelines make it quite clear that attending physicians must establish, among other things, "That they performed the service or were physically present during the key or critical portions of the service when performed by the resident ..."

This is a central principle and there is no exception for your specialty. Go to the CMS website and get a copy of the teaching guidelines (bit.ly/res-guidelines). There are  numerous versions of the attestations required to detail your level of involvement.

Specific Payment Questions

Q: I am an endocrinologist and I heard we can bill a patient for:

• Requesting documents and lab results from other clinics

• The physician's review of a patient's documentation from other sources, such as sugar logbooks, etc.

• Making phone calls to patients

• Refilling medications

Is this true?

A: All of the above items are somewhat oversimplified, with a grain of truth in some and less than a grain in others. If there is a code for something, theoretically it can be billed if performed. But, that does not mean that it is a payable service. That depends solely on whether that service in that circumstance is covered by a given payer's payment policy. Here is more guidance for each of the items you list above:

• Requesting documents and lab results from other clinics: No code or reimbursement exists for this.

• The physician's review of a patient's documentation from other sources, such as sugar logbooks, etc.: Code 99358, prolonged services non-face-to-face, could be used for this in the outpatient setting but is not generally reimbursed. In the inpatient setting, this could be included in the "floor time" aspect of time-based E&M services, if applicable.

• Making phone calls to patients: There are codes for phone calls: 99441-99443. However, these are also generally not reimbursed.

• Refilling medications: If problems are assessed and managed prescriptively in a face-to-face E&M encounter, and the documentation requirements of the code are met, then "refilling medications" is billable and payable. If medication is refilled, alone and/or without context, however, it is not a billable event.

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 January 2015 issue of Physicians Practice.