Mark Drexler, MD Wednesday 5/1/13 Inpatient Billing Mark Drexler, MD Wednesday 5/1/13

Objectives Understand the components that differentiate inpatient from outpatient physician billing Describe the factors that differentiate the levels of billing in initial and subsequent evaluation of hospitalized patients. Describe how billing on subsequent days of inpatient care should reflect the severity/ acuity of your patients’ illnesses

A Quick Review: Components of Billing (same as outpatient billing) CPT (Procedure) Codes – defines what you are doing ICD -9 (Diagnosis) Codes – defines why you are doing the above activity HCPC coding – defines supplies and medications given Modifier Codes – provide additional information for the insurance company detailing what you are doing.

Inpatient Billing: Adult Medicine

Initial Inpatient Evaluation Level HPI ROS FH/ SH EXAM A/P 99221 4 2-9 1-3 2-7 Simple 99222 10 >3 8 Moderate 99223 High

HPI Elements (Same) Location Quality Severity Duration, timing Timing Context Modifying factors Associated signs

ROS Elements (same) General / Constitutional Eyes Head / Neck Hematology/ Lymphatic Heart Lungs Musculoskeletal GI GU Neuro Psych Reproductive Skin

Past Family and Social History (same) Past - Describe the patient’s past experiences examples: Current medications
 Past illnesses/injuries/trauma Dietary status/Allergies Operations/hospitalizations Family – Medical events in the patient’s family examples: Health status or cause of death of siblings/parents Hereditary/high risk diseases
 Diseases related to the chief complaint, HPI, ROS Social – Describes age appropriate past and current activities examples: Living arrangements
 Marital status
 Drug or tobacco use Occupational/educational history

Exam (same) 15 Systems (Bullets): Constitutional (2) GU Male (3)   Constitutional (2) GU Male (3) Eyes (3) GU Female (6) Ears Nose Mouth & Throat (6) Lymphatic (4) Neck (2) MS (6) Resp (4) Skin (2) CV (7) Neuro (3) Chest (2) Psych (4) GI (5)

Subsequent Evaluation Emphasis on interim changes. HPI and ROS should reflect only data that impact decision–making for the patient’s condition(s). Exam may be limited to only those systems that impact decision-making for the patient’s condition(s). As acute illnesses resolve / stabilize, decision-making should reflect decreasing complexity.

Subsequent Inpatient Evaluation Level HPI ROS FH / SH EXAM A/P 99231 1-3 1 Simple 99232 2-7 Moderate 99233 4 2-9 High

Concurrent Care Multiple services, including the primary service and any sub specialists, providing care for a patient. Each service must document and bill only for the condition they are treating. On the day of initial consultation, the primary service may bill for the condition pertinent to the consultation. On days subsequent to the initial consultation, the primary service is unlikely to capture charges related to the condition being treated by any sub specialists.

Day of Discharge Reflects time spent coordinating care: 99238: <30 minutes 99239: >30 minutes Time does not have to be consecutive, face-to-face with the patient. Time spent on discharge coordination by house staff may not be billed by the faculty physician.

Day of Discharge (cont.) Time spent on day of discharge can include: Evaluation of the patient. Discussion with discharge coordinators, social workers and with the primary physician. Scheduling follow-up appointments. Direct patient / family education Documentation should include “>30 minutes spent on education and coordination of care.”

Same Day Admit / Discharge Hospitalization of < 24 hour duration All 3 billing levels require a comprehensive history and examination. Billing levels differ by complexity of decision-making: 99234: Simple 99235: Moderate 99236: Complex

Same Day Re-Admission Re-admission to the hospital within 24 hours of discharge Documentation and billing should reflect decision-making for subsequent inpatient evaluations rather than a new initial evaluation.

Time Based Billing Billing for time spent with patients on education/ counseling uses the following guidelines: 99231 – 15 minutes 99232 – 25 minutes 99233 – 35 minutes Documentation must support both the time spent and a summary of the discussion.

Summary Components of billing are similar for both outpatients and hospitalized patients. On subsequent days of care, billing / documentation should reflect the changing acuity of illness in the hospitalized patient. Multiple services treating the same patient for the same condition may not be reimbursed for that condition. Only time directly spent by the faculty physician, not the time spent by house staff, contributes to billing on day of discharge.

Questions?

Additional Areas To Cover OB (L&D) Billing Visits Newborn Billing Visits Pediatric Billing Visits

OB (L&D) Billing Visits 59400: Provide Prenatal Care and delivery via Vaginal (non operative or operative) 59409: Vaginal (non operative or operative) without prenatal care 59510: Provide Prenatal Care and delivery via Cesarean 59514: Delivery by cesarean without prenatal care *** Prenatal care provided but delivery done by OB (c-section) – no billing

Newborn Billing Visits 3 Levels: Initial Normal Newborn – billed by 1st provider to see newborn Subsequent Normal Newborn – billed by providers on each day after that (including discharge date) Same Day Normal Newborn Admission and Discharge – not done very often

Newborn Coding: Initial Care Evaluation and management services provided to normal newborns in the first days of life prior to hospital discharge are reported with Newborn Care Services codes. Codes for initial care of the normal newborn include: 99460: Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infants. 99461: Initial care, per day, for evaluation and managmeent of normal newborn infant seen in other than hospital or birthing center. 99463: Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date.

Newborn Coding: Subsequent Care 99462: Subsequent hospital care for the normal newborn is reported once per day. 99238 or 99239: Discharge services provided on a date subsequent to admission.

Pediatric Billing Visits Billed the same as adult inpatient visits: Initial Hospital Care Subsequent Hospital Care Discharge Services

Conclusion Inpatient and Outpatient Billing overlap in terms of components and elements needed to be documented. Differences are in the details of what comprises each level Billing for Obstetrical and Newborn Services are more straightforward.