Medical Billing Advisory: Hold Those Hospital Charges!

It seems like heresy: hold charges?  Isn’t it the best practice to post charges on the day they were provided and to submit those claims frequently? For most services, yes.  But, for hospital services there are good reasons to hold claims until after the patient is discharged.   Hospital services have a significantly higher error rate than services done in the office.  There are significantly more lost charges and denials for hospital services than office services.   Here are strategies to avoid those denials:

Be aware that the status of the patient may change

When submitting a claim for professional services provided in the hospital, the physician’s category of code (observation versus inpatient) must match the facility’s status.  Otherwise, the claim is denied.  Although it is the admitting physician who writes the order for observation or inpatient status, in practice, the case manager at the hospital decides if the patient meets the criteria for admission.  The physician’s billing status must match the hospital’s status in order to get the claim paid.

• For inpatient status claims, use these codes: 99221-99223, 99231—99233,  99238, 99239.  This is true for all payers.
• For observation status claims, use these codes: 99217, 99218—99220, 99224—99226.  CPT rules instruct physicians to use the new subsequent observation visits for patients in observation status who are not discharged the day after admission.  However, most Medicare contractors want only the admitting physician to use these codes, and all other physicians who see the patient in observation status to use office and outpatient codes, 99201—99215.
• For admission and discharge on the same calendar date, either status, use: 99234—99236.

Get a copy of discharge 99239 summaries

99239 requires that time is noted in the medical record.  It only takes a minute to check for that for each discharge billed with code 99239.  The documentation should read, “I spent XX minutes discharging this patient today.”  The time includes time spent with the patient, instructions for care to caregivers, preparation of discharge records, prescriptions and referral forms.

Check dates of service

Review the entire hospital stay when posting charges, making sure that there aren’t any days when two dates of service were charged or no visit was charged.  It’s easy to catch and fix these before charge posting.  For some admissions, the coder may need to look at the chart to be sure which physician saw the patient on which dates.

Use outside documents for verification

Missed charges, wrong dates of services, emergency surgery forgotten.  In the office, there is an appointment linked to an encounter for every patient.  If a charge isn’t posted, the billers can find it by running an exception report.  In the hospital, most groups rely on physician memory for charging.  Use operating schedules, census reports and copies of admissions or Emergency Department reports to verify that all services performed at the hospital are charged.

Many physicians turn in charges for services regularly and accurately.  Hospitalist groups may use electronic charge capture to minimize delay and forgetfulness.  But some physicians will always require assistance over and above the norm in order to have accurate, complete charging for out of office services.

Review all critical care notes and prolonged services notes

Medicare and CPT rules for prolonged services vary slightly.  CPT simply requires that the total time is documented in the record.  Medicare requires start and stop time for prolonged services, and the additional time must be face-to-face with the patient, not unit time.  For critical care, both CPT and Medicare allow the clinician to document the total time, rather than start and stop time.   Physicians of the same specialty in the same group who are both providing critical care services should report the initial episode of care (99291) only once. Additional 30 minute increments, after 74 minutes of critical care time, may be billed by the initial or subsequent physician on the same day using 99292. 

It is difficult for physicians to keep these detailed and confusing rules straight.  Although most physicians code most of their own services, critical care and prolonged services should get a second look by coders who understand the rules.  Because the rules are complex, and the RVUs high, review the documentation for these services before submitting a claim.

Holding and reviewing hospital charges will improve accuracy and decrease denials.  For these services, it may be necessary to physically review the note or the inpatient chart to determine correct coding.

Betsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org. You can hear Betsy speak in a complimentary recorded webinar presented by Kareo on “What You Can Do to Prepare for Medicare Payment Reductions.” In our July Getting Paid newsletter, Betsy wrote on “From Mad to Glad: Talking with Clinicians about Coding.”