Part B Insider (Multispecialty) Coding Alert

Published on Mon Nov 15, 2004 PDF

Warning: the distinction is not always obvious

When two physicians each have reason to believe they are the admitting physician, which one should be allowed to bill for the initial hospital visit? The answer could surprise you.

This question has caused confusion and payment problems for many physicians. Part B carrier HealthNow NY warned that some physicians who should have been billing for consults were billing for admissions instead (see PBI, Vol. 5, no. 38, p. 276).

"Providers who were rendering a consultation did not bill the appropriate consult code; they billed an admission code," HealthNow said. "We have received increasing numbers of appeal requests from admitting physicians who were denied payment for the initial hospital admission because another provider who saw the patient was the first provider to bill a claim as a hospital admission."

HealthNow went on to suggest that when a primary care doctor and a specialist are both treating a patient in the hospital, the primary care doc should be the admitting physician. This assertion has created a lot of controversy among billing experts, who say the specialist often should admit the patient instead.

Rule of thumb: The reason for the patient's admission should determine which physician is the admitting physician, say experts. For example, say a patient goes into the hospital for treatment of a cardiac problem, but she also has diabetes or other problems. In that case, the cardiologist should bill for the initial visit, and the physician who manages the other problems should bill for subsequent visits, say experts.

"The doctor who admitted them, who actually told the patient [to go to the hospital], who did the paperwork and wrote the orders for admission is the doctor who would bill for the initial hospital visit," says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, NJ. "The doctor whose opinion was requested would bill for the consult." This is true for two specialists as well as a primary care doc and a specialist.

If the patient is in the hospital for an orthopedic problem but an internal medicine doctor is managing some other systemic problems, then the internal medicine doctor will simply monitor the other systemic problems and leave the patient's management to the orthopedist, notes Sharon Tucker, president of Seminars Plus in Fountain Valley, CA.