Practice Management

CPT 2011 Update

On the Horizon

Prior reporting guidelines required the reporting of subsequent observation-care days with established outpatient codes (99212–99215). Some member plans insisted on referrals for all outpatient visits regardless nature of the service. Without the mandated referral for established patient visits performed in the observation setting, physician services were denied for coverage.

The creation of subsequent observation codes might play a role in decreasing these denials. Be sure to review the private payors’ fee schedules for inclusion of 99224–99226 codes. If missing, contact the payor or include it as an agenda item during your contract negotiations.

For more information on observation care services, check out “Observation Care” in the July 2010 issue of The Hospitalist. TH

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

References

  1. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology: Professional Edition. Chicago: American Medical Association Press; 2011.
  2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2011.

Physician Alert: Home Health Face-to-Face Encounter

Hospitalists have recently heard about—and fear the impact of—CMS-1510-F. This code is a condition of payment that will affect reimbursement to home health agencies, not hospitalists.

The Affordable Care Act of 2010 mandates that the physician who certifies a patient for home health services must document that a personal, face-to-face encounter, or an encounter with a qualified nonphysician provider, occurred. Prior to this regulation, hospitalists would certify home health services and be obligated to sign the plan of care to oversee post-discharge outpatient care, which placed hospitalists in a clinically awkward situation. CMS-1510-F expands and revises the guidelines:

  • A face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of home health care.
  • Face-to-face patient encounters can be provided by a qualified physician or nonphysician provider (e.g. nurse practitioner) who is working in collaboration with the physician in accordance with state law, or a physician assistant acting under the supervision of the physician.
  • Physicians who attended to the patient in an acute (hospitalists) or post-acute setting may certify the need for home health care based on their contact with the patient, initiate the orders for home health services, establish and sign the plan of care, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care.

While some might view CMS-1510-F as detrimental, hospitalists recognize its benefit: The certifying physician (e.g. hospitalist) no longer has to be the same physician who signs the formal plan of care (e.g. PCP).

For more information, visit www.cms.gov/MLNMattersArticles/downloads/SE1038.pdf and download further details of CMS-1510-F.—CP

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