Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 03, 2006 PDF

Educate  your physician to keep you in the loop on patients' development

Just because a patient enters the hospital with one diagnosis doesn't mean she'll have that diagnosis for her entire stay. And if you bill for your physician's hospital visits with an out-of-date diagnosis, you could lose money or face fraud charges.

The problem: Diagnoses can change in the hospital because:

• The physician may narrow down the patient's problem. For example, a patient may be admitted with chest pain, and the doctor may rule out myocardial infarction and decide the problem is gastrointestinal, says Pat Larabee, a coding specialist at InterMed in South Portland, ME.

• The patient may develop other problems. The patient may be admitted for heart problems but may start having terrible headaches, says Larabee.

• The patient may experience complications, says Larabee.

You can't wait for the hospital to send you medical records and hope to bill in a timely fashion, says Larabee. You could be waiting six weeks after the patient gets out of the hospital for any records. So it's up to your physician to let you know if a patient's diagnosis has changed.

Do this: Educate your physicians, and "let them know that just because the patient has been admitted with a particular diagnosis doesn't mean they should bill for that diagnosis for each visit," advises Larabee.

InterMed gives each physician a simple form to record hospital visits, says Larabee. The physician puts a sticker with the patient's hospital identifier on the form and then writes the date of each visit, the level of service and the diagnosis. Each sheet will have room for 10 or 12 patient visits.

Diagnosis Tracking Is In The Cards

Another approach is to give your doctor a bunch of index cards that fit in the pockets of a lab coat, says Suzan Hvizdash, a physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. The physician uses one card for each patient and notes each visit to the patient for a given week. At the end of the week, the physician turns in each card. The cards have a space at the bottom for the patient's diagnoses, which the physician can add a date to.

If your physician doesn't admit the patient to the hospital, then chances are the diagnosis won't be the admitting diagnosis anyway, notes Hvizdash.

For example: Your doctor performed gall-bladder surgery on the patient two months ago. Your doctor wouldn't know the patient was admitted for pneumonia, unless the admitting doctor called the surgeon in to check on the surgery. So your surgeon would bill under the post-operative gall bladder diagnosis, not pneumonia, says Hvizdash.

Watch out: If you're not billing with the most up-to-date diagnosis, you may not be able to justify a higher level of service, notes physician and coder James Kennedy. The patient may have been admitted with a simple problem and then developed complications, so a subsequent visit could have more complex medical decision-making. But you won't be able to justify a higher level code unless you know all the diagnoses, says Kennedy, senior physician executive with FTI Cambio Health Solutions in Brentwood, TN.

Penalty: Also, billing with an incorrect diagnosis could be considered a false claim, and your practice could be fined up to $10,000 plus three times the amount you billed, Kennedy warns.