Medicare Compliance & Reimbursement

'Bounty hunters' may be scrutinizing your inpatient E/M visits.

Myth: A physician can bill for a hospital "admission" even if she didn't see the patient in the hospital.

Truth: In fact, there's no code for hospital admission. To bill for an initial inpatient visit (99221-99223), the doctor must visit the patient in the hospital and perform a history and physical exam there.

Oftentimes, the physician will see the patient in the office and then admit him to the hospital. The doctor may not see the patient in the hospital on the same day, but will still want to bill for an initial inpatient visit because she performed a history and physical exam in the office before admitting him.

There was a "lengthy discussion" about billing for initial inpatient visits at an American Academy of Professional Coders conference some years ago, says Suzan Hvizdash, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. In the end, the coders decided that the place of service should decide which code your doctor bills. But many coders remain confused.

"If the doctor goes to see the patient in the hospital, is he/she going to retrieve the same history and do the same exam as was done in the office?" Hvizdash asks. "Probably not." And usually the doctor won't see the patient until the next day. So in these cases, you should bill for the office visit instead of an initial inpatient visit.

Important: Make sure your doctor's documentation accurately states where the history, physical exam and medical decision-making took place, Hvizdash urges.

Warning: The Recovery Audit Contractors (RACs) will be looking at inpatient visits because of their high error rate, warns Collette Shrader, compliance and education coordinator with Wenatchee Valley Medical Center in Wenatchee, WA.

The RACs will especially look at initial inpatient visits "because of the high documentation requirements," Shrader says.

It can be hard to tell whether the physician has seen the patient on-site at the hospital because many physician offices will have hospital "packets" that they send along with the patient to the hospital, Shrader adds. These packets often include order sheets and progress note pages where the physician can handwrite orders.

Bottom line: To figure out if the doctor actually made it to the hospital, you should examine the doctor's schedule, and also ask the doctor, says Shrader.