Billing Tutorial - Carmen Wiki

Inpatient Billing Three components of History and Physical: Need 3 out of 3 1. History: Chief complaint-must list this! HPI: mention at least 4 of the following: location, quality, severity, duration, timing, context, modifying factors, associated signs/sx Past Medical History-list 1 Family history-list 1 Social history-list 1 (need 3 for Medicare/Medicaid, though) Review of Systems: mention at least one item from 2 different systems, then could state “Full 10 point review of systems otherwise negative”. Must also document if this is unobtainable and why 2. Physical Exam: document 8+ body systems for level 3 billing 3. Medical Decision Making Initial Visit codes: Level 1, approx 30 minutes 99221 Level 2, approx 50 minutes 99222 Level 3, approx 70 minutes 99223 Three components of daily note: Need 2 out of 3 1. History-cannot just write “follow-up”, instead write “follow-up for hypertension”. Include 4 elements HPI and 2 elements of ROS for level 3 billing 2. Physical exam 1 to 6 systems level 2---2 to 7 systems with 1 detailed for level 3 3. Medical Decision Making: straightforward, low complexity, moderate, or high a. Diagnoses or Management options Number of self-limiting/minor problems (max of 2) x1pt Number of established diagnoses/problems (stable/improved) x1pt Number of established diagnoses (worsening) x2pts Number of new problems with no additional workup (max of 1) x3pts Number of new problems with additional workup planned x4pts b. Amount/complexity of data reviewed Review/order clinical lab test x1pt Review/order tests in 7xxxx or 9xxxx series of CPT x1pt Discuss test with interpreting provider x1pt Independent review image/tracing/specimen x2pts Review and summarize old records/history x2pts c. Risk related to diagnoses, diagnostic procedures, or management options High risk drugs like vancomycin or IV narcotics justify high risk: document what you are following (HR, RR, vanc levels, Cr, etc) Minimal = 0 to 1 point Limited = 2 points Moderate = 3 points Extensive = 4 points

To qualify for a given level of complexity of Medical Decision Making, document that two out of three components listed above meet that level Subsequent care codes: Level 1, 15 minutes 99231 Level 2, 25 minutes 99232 Level 3, 35 minutes 99233 If more than 30 minutes spent beyond these expected times to complete initial visit or subsequent care, can add a prolonged service code. Document this time in note. Teaching physician with resident: Add “GC” as modifier and add attestation -Only 4 dx/problems per billing day: list them in order of severity, add new ones if they arise. However, list all problems on your note as this attests to medical complexity -code symptoms only if problem is undiagnosed (“dyspnea” is okay but “PE” is better) Discharge: 1. discharge codes are based on time which you need to document: Less than or equal to 35 minutes, or greater than 35 minutes. Must also document a physical exam on day of discharge 2. Can’t bill for an initial visit and a discharge on the same day. Just use the admit code or “admit and discharge, same day” Critical care: 1. Bill as just an E/M code/subsequent care if less than 30 minutes spent 2. Can bill an E/M code plus a critical care code (30 to 74 minutes spent) if these services occurred at different times in the day, and can only do this on the first day. Subsequent days spent in ICU/critically ill would only use the critical care code 3. Endotracheal intubation and central line placement are separately billable (use modifier 25) but the time spent performing these are NOT included in critical care time. CPR is separately billable. Document one or more organ failure 4. Need to document the actual time spent, must be at bedside or on the unit. Can add up times spent throughout the day. Don’t write “stable” anywhere! Consults: 1. Need to have a documented request for the consult 2. Usually a pre-operative eval can justify a level 5 billing code 3. bill follow-up days as Subsequent Care like you would for your own service patients Observation: 1. If admit and discharge on same day, use Initial observation code 99218-99220 2. If stays until next day, bill observation care discharge services, 99217 3. If admitted under obs, but changed to admit on the same day, only bill the admission code

Q: If my partner admits the patient at 5am, and I visit them at 12pm, can I bill a subsequent care charge? A: No. Subsequent visits on day of admission fall under the admission code. Only one physician per day per group can enter an E&M code. However, could add up the time spent by both physicians to justify a higher admission code entered by the admitting physician Q: If I do a consult on a patient and then decide to transfer them to my service, can I bill the consultation and as an Initial Inpatient visit (admission)? A: No. Have to choose one E/M code, and if you transfer them without doing a consult and write an accept/follow-up note, you would just bill this as subsequent care Q: Can I bill a subsequent care visit E/M code in addition to a ventilator care code (Initiating ventilator support 94002 or subsequent ventilator management 94003)? A: No. Ventilator management codes are bundled into hospital visit codes. Pick one. Q: How do I bill for pronouncing a death? A: Can use a discharge code, 99238 or 99239 Q: Can I bill for Critical Care 99291 instead of inpatient consult 99255 if I performed critical care? A: yes, as long as patient was critical while you saw him/her and you spent more than 30 minutes in critical care Q: If my partner admits a patient after midnight, and I see the patient and discharge him later that day, can I bill for the discharge? A: No. Could bill “same day admit and discharge” but only one physician, not both, can enter this charge Q: If I have to spend a lot of time with a patient that my partner admitted earlier in the day, can I bill for prolonged service code separately from my partner’s Initial visit code? A: No. You should enter the prolonged service code anyway, however, as this time can be added to the admitting physicians billing code to justify higher billing. But the second physician doesn’t get “credit” for this in our system Q: Can I bill for critical care on the same day as my partner’s admission or subsequent care billing? A: Yes. And the second physician will get “credit” for this in our system