Question #1: What must be done documentation-wise by the attending physician to ensure that the optimum billing level is captured for this patient? What is not acceptable in this setting?
Answer: Redocumentation by the teaching physician is relatively minimal since CMS revised its guidelines [Transmittal 1780 dated 11/22/02], which allows substantial reference to the resident’s note in addition to a personal note, however, documentation must clearly demonstrate that the teaching physician was physically present during the key portions of the service billed. Examples of documentation provided by CMS are:
“I performed a history and examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
Or
“I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.”
Or
“I saw and evaluated the patient. I agree w/ the resident’s note except…” while noting the difference in plan, etc.
Question #2: If the hospitalist/medical resident write the orders for the heparin and V/Q scan, does this constitute comanagement and prevent billing this as a consult?
Answer: A consultant may initiate treatment at the conclusion of his evaluation and still bill a consultation code as long as the other requirements have been met (i.e., a request for opinion regarding evaluation and treatment and no advance transfer of care). There are no specific rules related to medical residents in this scenario, so if the teaching physician is performing the consult in a timely manner with the resident, a consultation could still be coded appropriately.
Summary
Although efforts have been made by Medicare to clarify the vagaries of coding for consultative work, existing guidelines remain complex and not necessarily intuitive. This article has attempted to shed light on some of the more commonly encountered situations with which hospitalists grapple, but is unable to address all of the questions that may arise. Hospitalists and hospital medicine groups are encouraged to familiarize themselves with current coding guidelines and to establish and maintain strong relationships with local coding professionals. Future issues of The Hospitalist will tackle additional coding questions.
Dr. Pfeiffer can be contacted at [email protected].