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Initial vs. Subsequent Hospital Care

  1. Default Initial vs. Subsequent Hospital Care
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    I have a facility that is using a PA to go out and do an exam on a patient for an admit before the admitting physican goes out to do their initial service (this occurs the day before the admitting physician sees the patient). Because the PA is performing a limited service and is not the admitting physician, the facility is billing a subsequent care code for the PA and then the initial code for the admitting physician on the next day. It is my impression that you cannot bill for a subsequent hospital service prior to an initial. The facility insists they can do it because the CPT manual does not state that the initial must be billed first. While it is not specifically stated in writing, I believe that is just inferred by the code description. For the PA service, it does not appear that a consult would fit as the decision to admit is already made and this is a routine method that the facility follows when admitting patients. My sense is that the PA service is not billable and then the admitting physician bills for initial hospital care the day he sees the patient. Anyone have any suggestions?

  2. #2
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    Quote Originally Posted by pcc@drchoate.com View Post
    I have a facility that is using a PA to go out and do an exam on a patient for an admit before the admitting physican goes out to do their initial service (this occurs the day before the admitting physician sees the patient). Because the PA is performing a limited service and is not the admitting physician, the facility is billing a subsequent care code for the PA and then the initial code for the admitting physician on the next day. It is my impression that you cannot bill for a subsequent hospital service prior to an initial. The facility insists they can do it because the CPT manual does not state that the initial must be billed first. While it is not specifically stated in writing, I believe that is just inferred by the code description. For the PA service, it does not appear that a consult would fit as the decision to admit is already made and this is a routine method that the facility follows when admitting patients. My sense is that the PA service is not billable and then the admitting physician bills for initial hospital care the day he sees the patient. Anyone have any suggestions?
    Why would the PA go out and see the patient? why wouldn't the physician just do the admit H&P and bill for it? I don't see why the PA should be involved - and where is the PA seeing the patient at, outpatient or inpatient? If the patient isn't "admitted" you can't bill for an "inpatient subsequent care" visit. Subsequent hospital cares are specific to "inpatient" only. I think they have misinterpreted the code by far. No consult here at all. Or - has the order been given to admit by the admitting MD... he hasn't gotten there yet and the PA sees the patient?

    Is the PA in the same group as the admitting physician? I have never had this come up - I just don't see why it's necessary for the PA to see the patient. It's like they're trying to get something extra in. If the admit and subsequent care are billed on same day, by same group - you're only going to get paid for one. Which of course, the admit should be billed - more $$. If different group, they might be able to get away with it <if the same diagnosis is used, it still might deny> For different days (you said day before) I'd need more detail...but regardless, doing this on a "routine" basis just doesn't seem right to me....

    Hope this helps....Please clarify if I interpreted this wrong.
    Last edited by ARCPC9491; 08-14-2008 at 11:06 PM.

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