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Need Clarification - Please Help!

  1. #1
    Default Need Clarification - Please Help!
    Medical Coding Books
    I need to get some clarification on this, because it's causing some confusion - if anyone can cite a regulation, that would be fantastic!

    Scenario 1: Let's say that a patient goes to the ED on 1.1.11 at 10pm - the ED physician performs the H&P, and then calls the patient's PCP (an internist) to discuss their condition, and see if he wants to admit them. The PCP gives orders to admit over the phone, and the patient is admitted that night. He comes in the next morning (1.2.11) and performs his H&P. How would the PCP bill for this situation?

    The debate is: whether or not the PCP billing 99222-AI for DOS 1.2.11 is correct.
    I said no, but now I'm second-guessing myself. I guess what I really need to know is, what does it really mean (from a coding/billing standpoint), to be the admitting physician of record? Does having that designation have any kind of impact whatsoever on the way that the encounter is billed/reviewed/paid (for anyone - the PCP, other providers involved in care, the hospital)?

    Also, are there specific requirements on when the physician must perform the H&P, to be considered the admitting physician of record? I guess what I really don't understand is:
    1. Why does it matter who the admitting physician is, if every doctor from a new specialty can report an initial hospital code - it seems like it would be a pointless formality if it didn't have some kind of affect on something, but all of the info I'm finding seems to support the pointless-formality theory. If using the AI modifier is just "FYI", and nothing else, then why is using it really important? I have a hard time grasping rules that seem arbitrary, and want to believe that the mere fact that this modifier exists in the first place, should indicate that it would serve a useful and noticable purpose, but I'm having a really hard time finding trustworthy info to support my original opinion.

    2. Assuming that being the 'admitting physician of record' does actually have a discernable impact, eventually, does a doctor have to perform an H&P on the patient on the same day that they were admitted, to report that they are the AI; or do they only need to supply the order for the admission to qualify? It just seems wierd that the 'admitting physician of record' would bill an initial inpatient visit on a date of service that was subsequent to the actual admission, but I guess it's a possibility. The more I read on this, the more confused I get.

    Scenario 2:
    Same as Scenario 1, except this time, the PCP saw the patient in his office on 1.1.11 for the same problem that got them admitted; and he bills a 99212.

    Has the fact that the PCP saw the patient in his office on the same date that they were technically admitted as inpatient, changed anything about how this should be billed, since the PCP has designated himself as the 'admitting MD of record'? CPT guidelines on reporting services from another site of service, on the same date as the admission, are tripping me up on this one. If I understand this correctly (and please let me know if I don't), if the patient sees a doctor in another site of service (ED, their office, etc.) for a problem, and then is admitted to the hospital by the same physician, later in that same day, then all of the services provided by the MD on that date are bundled into the initial hospital care. But does this situation represent a loophole in that rule? The PCP couldn't bill the 99222 on 1.1.11, because he hadn't performed an H&P on the patient at the time that they were admitted - giving an order over the phone doesn't qualify as 'initial hospital care', according to the CPT definition, so if the H&P wasn't done until the next day, will the admitting physician be able to collect both an outpatient office visit and an initial inpatient visit for the same patient, just because he didn't make it in to re-evaluate the patient personally, until the next day?

    Something about all of this really rubs me the wrong way, but hospital charges aren't my strongest area, so I could easily see myself over-analyzing this and trying to make it harder than it is. I think I've tied my brain in a knot trying to understand this crap...Please help me!!! Thanks!

  2. #2
    Location
    Everett, WA
    Posts
    886
    Default
    Brandi, I've been wondering about this myself and if you don't get an answer by the time our next chapter meeting rolls around (next Tuesday), will take it to the group for a roundtable discussion if time permits. Glad you asked this first! Otherwise it would have been me posting this question to the forum..

    ---Suzanne E. Byrum CPC

  3. #3
    Default
    I've got to get this figured out! It's like there used to be a system that recognized when an encounter was related to the actual admission, and now there's really not one anymore - how do they establish medical necessity for the admission, without a clearly defined evaluation by the 'admitting' physician on the day that they were admitted?!?! I have to stop...I'm just confusing myself even more...

    I really hope somebody can explain this in a way that it makes sense...

  4. Default Need Clarification - Please Help!
    Brandi,

    I agree with you, the patient was admitted on 1/1/11; so, when the PCP sees them on 2/2, they are not admitting because patient is already an inpatient.

    Yes, the admitting physician is in a special class and you will have to review this for their responsibilities.

    Now, in your second scenario, the doctor should combine the office visit and hospital visit to arrive at the correct level for admitting (in other words, the office visit may be able to boost the admission level if documented correctly).

  5. #5
    Default
    Quote Originally Posted by DRWINGCHUN View Post
    Brandi,

    I agree with you, the patient was admitted on 1/1/11; so, when the PCP sees them on 2/2, they are not admitting because patient is already an inpatient.

    Yes, the admitting physician is in a special class and you will have to review this for their responsibilities.

    Now, in your second scenario, the doctor should combine the office visit and hospital visit to arrive at the correct level for admitting (in other words, the office visit may be able to boost the admission level if documented correctly).
    Thanks for the reply!

    I can't combine the office visit and hospital visit, because technically, the doctor didn't have a hospital "visit" until the next day - he ordered admit over the phone. I can't combine 2 separate DOS. So what do I do? Billing the 99212, and then also getting reimbursed for an initial inpatient visit, when he's technically the admitting MD, sounds like a form of double-dipping to me. Had he made the trip to the hospital that same night and evaluated the patient then, he would have only been paid for the inpatient visit, and rightly so. By waiting a day to meet an E/M requirement for initial hospital care, he side-stepped the bundling. Can he do that?

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default DOS is date patient seen
    # 1) You are confusing an H&P - which is a HOSPITAL required document - with an INITIAL HOSPITAL VISIT.

    The ED physician's documentation will be used to code his ER visit.
    The admitting physician's documentation will be used to code his INITIAL HOSPITAL VISIT.

    Makes no difference if the patient isn't seen until after midnight. This happens all the time in hospitals with staff on duty 24-7. Patient shows up in the ED in the late evening, is transfered to admitting physician/hospitalist service but hospitalist doesn't get to see patient until after midnight.

    THe initial hospital visit is coded w/ DOS that matches the actual date the admitting physician saw the patient face-to-face in the hospital for the first time.

    # 2) CPT guidelines specifically tell us to use ALL the face-to-face services provided in order to determine the level of Hospital Admission (CPT 9922x) when that patient is admitted on the same DOS as the outpatient services are performed. This is true when the PCP is also the admitting physician, or another physician in the same practice with the same specialty is admitting the patient.

    HOWEVER ... if your PCP sees the patient in the office for - let's say diabetes. And later the same date of service, the patient goes to the ER and is admitted for diabetes by a physician NOT IN THE SAME PRACTICE/SPECIALTY as PCP, then each of them will correctly bill out the service s/he provided.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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