Question hospital E/M

Messages
4
Location
Tucson, AZ
Best answers
0
Please help! I'm new to this type of coding... I work for a clinic in which we do most procedures here, but sometimes we need to send patient to a local hospital, in which my provider will perform the procedure there instead. My question is if my provider is listed as the "admitting" doctor, can we code/bill for the (99221-99223)(and does it need mod AI)? My doctor does not think so, saying it's double dipping. Another biller thinks it's based on if the surgery was "scheduled" or not (if scheduled its bundled into the office exam as sx preop work). I'm thinking as long as it is not on the same day, we can bill for it. (if 99201-99215 and 99221-99223 same day, you bill one or the other, typically the hospital code instead of office). Any clarification, tips, guidelines, help of any kind would be greatly appreciated! Thank you!!!
ps.. I'd take any advise/guideline info on hospital initial exam, subsequent exam, discharge, and consults! :)
 

lcolborn

Guru
Messages
127
Best answers
0
If the patient sees the doctor in the clinic and sends them to the hospital for a procedure, can you bill for the E/M and what E/M Codes? , is this the question?
Anyhow, rule of thumb , if the patient is seen in the clinic and sent to the hospital for admission/inpatient, you cannot bill for the E/M in the clinic..., only the initial hosp visit. Now, if the patient is being sent to the hospital for an outpatient procedure same day they saw the doctor in the clinic, you could bill the E/M (99202-99215 ) .
 
Messages
4
Location
Tucson, AZ
Best answers
0
If the patient sees the doctor in the clinic and sends them to the hospital for a procedure, can you bill for the E/M and what E/M Codes? , is this the question?
Anyhow, rule of thumb , if the patient is seen in the clinic and sent to the hospital for admission/inpatient, you cannot bill for the E/M in the clinic..., only the initial hosp visit. Now, if the patient is being sent to the hospital for an outpatient procedure same day they saw the doctor in the clinic, you could bill the E/M (99202-99215 ) .
Thank you for your response! I should clarify; this would be on different days.. for example, pt seen in the clinic in January, and we bill a 99213. At that visit Dr determines pt will need surgery that is scheduled at hospital, as IN-patient, for the following month. In February, our Dr is listed as the admitting Dr. He does an exam before surgery. Pt stays at least 1 day as an IN-patient. Would we be able to bill a 99221 on that admit date in February?
 

lcolborn

Guru
Messages
127
Best answers
0
Thank you for your response! I should clarify; this would be on different days.. for example, pt seen in the clinic in January, and we bill a 99213. At that visit Dr determines pt will need surgery that is scheduled at hospital, as IN-patient, for the following month. In February, our Dr is listed as the admitting Dr. He does an exam before surgery. Pt stays at least 1 day as an IN-patient. Would we be able to bill a 99221 on that admit date in February?
Yes if he does an Initial Inpatient visit with the HPI , ROS and the likes before the surgery, and not just seeing them in the operating room before the surgery. Here you will have an Initial Inpt visit, surgery, maybe a subsequent, and a discharge .
 

AmandaBriggs

Expert
Messages
275
Location
Coeur d'Alene, Idaho
Best answers
1
I disagree with the response above and encourage you to read the MLN Global Surgery Booklet by CMS. If the provider has already determined that the patient needs surgery, then the H&P would bundle into the global surgery payment. Per CMS, "Medicare includes the following services in the global surgery payment when provided in addition to the surgery: Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-operative visits the day before the day of surgery." If the surgeon is addressing other concerns outside of those prompting the surgery, then the H&P could be billed with a modifier. All of the documentation pertaining to the surgery would have to be disregarded when leveling the service. Here is a link to that booklet: https://www.cms.gov/Outreach-and-Ed...oducts/Downloads/GloballSurgery-ICN907166.pdf
 

csperoni

True Blue
Messages
1,016
Location
Selden
Best answers
3
I strongly second Amanda's vote for the visit prior to a planned major surgery is included in the global package. I refer to the Medicare global surgery booklet referenced regularly. I am assuming this is a major surgery (90 day global) if the patient is inpatient and admitted to the hospital. There are 2 specific items there that I believe are relevant here, both stating the inpatient visit is not billable separately. If this was not a planned surgery, then my advice would differ. I also suppose there are scenarios where a patient might be admitted for a minor procedure with zero global, but I can't recall having that scenario ever. Perhaps some input on the procedure being done (minor with zero global, minor with 10 global, major with 90 global) could clarify the differing opinions.

What services are included in the global surgery payment? Medicare includes the following services in the global surgery payment when provided in addition to the surgery:
• Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
• Intra-operative services that are normally a usual and necessary part of a surgical procedure
• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
• Post-surgical pain management by the surgeon
• Supplies, except for those identified as exclusions
• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

90-day Post-operative Period (major procedures).
• One day pre-operative included
• Day of the procedure is generally not payable as a separate service.
• Total global period is 92 days. Count 1 day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery.
 
Top