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Initial Hosp Care + Prolonged Service by 2 Different Hospitalists from Same Group

  1. Question Initial Hosp Care + Prolonged Service by 2 Different Hospitalists from Same Group
    Medical Coding Books
    Lots of questions posted about Prolonged Services, but I couldn't find one addressing this specific question:

    . Hospitalist group
    . One hospitalist admits patient & bills 99223
    . Second hospitalist sees patient later & bills prolonged service (99356)

    Assume all of the time and documentation criteria are met to bill these codes. Question: Is it appropriate to bill 99223 for one hospitalist and 99356 for another hospitalist? Medicare has rules in its Physician Claims Processing Manual at 30.6.5 stating that physicians in a group practice should bill as a single physician; however, the language in the Prolonged Services section (30.6.15) consistently refers to the "same physician" providing both the base E/M service and the prolonged service. Since 99356 is an add-on code, billing it on a separate claim under the second hospitalist will surely hit a claims-processing edit. I am to the point of convincing myself that the prolonged service codes must be billed by the same physician who billed the base code. Is this consistent with the thought / knowledge of others?

    Thanks for any help anyone can provide.
    Nancy, CPC, CPC-H

  2. #2
    There is a good bit of discussion about this out on the web, I researched it one day.

    In theory, they should be able to bill under their own numbers since they are considered the same provider. In practice though, Medicare will generally deny the add on code since it is not under the same provider as the primary code. The discussions I ran across were about critical care provided in the same manner, the billing of these services are essentially the same in this situation.

    There was heated debate as to why it matters who it is billed under. Obviously the biggest issue to many is compensation, a lot of providers are paid based on volumes, so the 2nd provider is going to get short changed.

    I personally think we should bill it correctly (under the provider of service) and fight it out or else it will never get fixed in their systems.

    Just my opinion,

    Laura, CPC, CEMC

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