Hospital Medicine

Billing basics - consults, prolonged services and procedures

I. Problem/Challenge.

In addition to admissions, discharge and daily patient care, hospitalists also perform consultations, prolonged services and bedside procedures, and must bill appropriately for these additional services. Physicians can select the appropriate Current Procedural Terminology (CPT) codes to bill for these services.

II. Identify the Goal Behavior

Consultation

An initial hospitalist consult requires comparable documentation to an initial admit however it must also include the consulting physician’s name and reason for consultation. An “-AI” modifier is added to the evaluation & management (E&M) code of the principal/admitting physician to differentiate the physician overseeing care from a consultant since the same codes are utilized.

Prolonged services

Prolonged services can be billed when a hospitalist has spent an additional 30 minutes or more beyond the typical time spent for the initial E&M code. This includes time spent face-to-face with the patient, coordinating care or reviewing data. The total time spent must be clearly documented in the medical record.

Procedures

Procedures are billed separately based on the procedure done. A “-25” modifier must be added to the E&M service (i.e. subsequent care code) to identify this as a “significantly, separately, identifiable E&M service done on the same day”.

III. Describe a Step-by-Step approach/method to this problem.

CONSULTATIONS (CPT 99221-99223)

  • Document who is asking you to do the consult

  • Document the reason for consultation

  • Document a full history and physical exam and bill as you would for an initial admit

See the chapter “Billing basics - admits, subsequent care and discharge” for details.

Prolonged services

Prolonged services capture time you spent in addition to the time required for the initial E&M code. These are to be used primarily when treating patient with complex and concerning presentations.

First 60 minutes of face-to-face services (CPT 99356)

An add-on code for additional time spent after the primary E&M service has been completed. The threshold for a 99356 code is met after 30 minutes more than the established time for the initial E&M code has been spent face-to-face with the patient, coordinating care or reviewing data. The total time must clearly be documented and does not need to be continuous.

For example: Typical time spent on level 2 subsequent care encounter is 25 minutes. In order to meet the criteria for an addition 99356 code, a total of 55 minutes must be spend with the patient (25 minute for the 99232 + 30 minutes for the 99356).

Each additional 30 minutes (CPT 99357)

This code is used when the physician has filled the time allotted for the initial E&M code, the 99356 requirement (60 minutes), plus at least 15 additional minutes face-to-face with the patient, coordinating care or reviewing data. So if a physician bills a level 2 subsequent care (99232) plus prolonged services 99356 AND 99357 s/he must have spent and documented over 100 minutes face-to-face with the patient, coordinating care or reviewing data. (25 minutes for 99232 + 60 minutes for 99356 + 15 minutes for 99357 = 100 minutes.)

Procedures

Procedures require a separate note and must be identified as separate from the initial E&M code for that day by placing a “-25 modifier” to the initial E&M charge (Table I).

Table I.

Procedure codes

  • Arthrocentesis:

20600 – small joint – finger, toe

20605 – medium joint – wrist, elbow

20610 – large joint – knee, hip, shoulder

  • Incision and drainage:

10060 – drainage of skin abscess

  • Paracentesis:

49082 – abdominal paracentesis (diagnostic or therapeutic); without image guidance

49083 – abdominal paracentesis (diagnostic or therapeutic); with image guidance

  • Thoracentesis:

32554 – aspiration of pleural space, without image guidance

32555 – aspiration of pleural space, with image guidance

32556 – pleural drainage with insertion of indwelling catheter; without image guidance

32557 – pleural drainage with insertion of indwelling catheter; with image guidance

  • Cardio-pulmonary resuscitation (CPR):

92950 – if a code is called and CPR is performed

  • Central line:

36556 – placement of central line

  • Arterial line:

36620 – placement of an arterial line

IV. Common Pitfalls.

Clearly document time spent.

Use a “-25” modifier on days when a procedure AND admit/subsequent care/discharge are being billed.

Bill for prolonged services when time spent with a patient exceeds the typical time for the selected service code by more than 30 minutes. These codes should be used carefully and judiciously as they may be red flags for increased scrutiny of bills.

V. National Standards, Core Indicators and Quality Measures.

1995 and 1997 Documentation Guidelines for Evaluation and Management Services.

VI. What’s the evidence?

"Department of Health and Human Services, Centers for Medicare and Medicaid Services: Evaluation and Management Services Guide".

"Department of Health and Human Services, Centers for Medicare and Medicaid Services: Evaluation and Management Services".

"CodeManager: CPT Code/Relative Value Search, American Medical Association".

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