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Reasons for Denial

Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:

  • Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
  • Services by one physician duplicate or overlap those of another provider without recognizable distinction.2

For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.

Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.

Group Practice

Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.

The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.

Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.

References

  1. Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
  2. Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
  3. Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
  4. Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
  5. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.

Coding Reminders: Subsequent Hospital Care

99231: Subsequent hospital care, per day, for E/M of a patient, which requires at least two of these three key components:

  • A problem-focused interval history;
  • A problem-focused examination; and
  • Medical decision-making that is straightforward or of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.5

99232: Subsequent hospital care, per day, for E/M of a patient, which requires at least two of these three key components:

  • An expanded problem-focused interval history;
  • An expanded problem-focused examination; and
  • Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.5

99233: Subsequent hospital care, per day, for E/M of a patient, which requires at least two of these three key components:

  • A detailed interval history;
  • A detailed examination; and
  • Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.5

Report subsequent hospital care codes once per day after the initial patient encounter date (i.e., admission or consultation service), but only when a face-to-face visit occurs between the reporting provider and the patient. The visit entails bedside care but might include other important aspects performed on the patient’s unit or floor, such as data review, discussions with healthcare professionals, care coordination, and family meetings. The 99231-99233 codes are “per day” codes and represent the cumulative service performed on a calendar date, even if the physician evaluates the patient for different reasons or at different times throughout the day.

Note: The physician does not have to spend the associated “typical” visit time with the patient in order to report an initial hospital care code. Time is only considered when more than 50% of the total visit time is spent counseling or coordinating patient care. For more information, visit www.cms.hhs.gov/manuals/downloads/clm104c12. pdf.—CP

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