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Physician Billing. Charles F. von Gunten, MD, PhD, FACP Medical Director, Center for Palliative Studies San Diego Hospice & Palliative Care Associate Clinical Professor of Medicine University of California, San Diego. Major Topics. Coding Documentation Reimbursement. Nurse Practitioners.

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physician billing

Physician Billing

Charles F. von Gunten, MD, PhD, FACP

Medical Director, Center for Palliative Studies

San Diego Hospice & Palliative Care

Associate Clinical Professor of Medicine

University of California, San Diego

major topics
Major Topics
  • Coding
  • Documentation
  • Reimbursement
nurse practitioners
Nurse Practitioners
  • The mechanics of physician billing ARE THE SAME for nurse practitioners
  • There are State by State variations in requirements for documentation, supervision, and scope of practice.
coding for physician services
Coding for physician services
  • 2 Codes
    • CPT Procedure/Service Code
    • ICD-9-CM Diagnosis Code
  • Fee
    • Physician Fee
    • Payer’s fee schedule
    • Permissible co-payment
  • Total income reflects payer mix
cpt codes
CPT Codes
  • Current Procedural Terminology

Source for all physicians, published by AMA

Evaluation and Management Codes



Physical Examination



coding by components
Coding by Components
  • History

Limited vs Extensive

  • Physical Examination

Limited vs Extensive

  • Decision-making

Straightforward vs serious

counseling information
  • If more than 50% of a patient/physician interaction is comprised of counseling and information giving, then time can be used to determine which E/M code is used
    • Inpatient, total time on unit
    • Outpatient, total face-to-face time
case example
Case Example…
  • 4 pm walk on unit, review chart, interview and examine patient, discuss diagnosis and prognosis.
  • 5 pm. Reviewed radiographs. Discussed with pulmonology, cardiology, cardiac surgery. Discuss w/ attending, nursing staff. Returned to discuss findings with patient for additional 30 minutes. Then documented in medical record
  • 6:30 pm complete.
  • You spend an additional 30 minutes obtaining consent, assembling the supplies, performing the procedure, and documenting this in the chart.
  • 150 minutes total time on unit.
  • 90 minutes face-to-face with patient. 60 min. related to information giving and counseling.
  • Recommend morphine for dyspnea and therapeutic thoracentesis for pleural effusion.
case example coding
Case example coding
  • CPT E/M Code
    • 99255 (110 min)
    • 99356 (40 min)
  • Diagnosis Code
concurrent care
Concurrent Care
  • 2 physicians providing care to the same patient on the same day
  • Permitted
  • Coding reflects the differences
  • Documentation supports the codes and describes the need and services provided
concurrent care20
Concurrent Care
  • Document care provided
  • Use different ICD-9-CM codes
concurrent care coding example
Concurrent Care Coding Example
  • Woman with pulmonary fibrosis, aortic aneurysm, dyspnea

In addition, CPT Code for paracentesis and ICD-9 code

for pleural effusion if it is done by consultant

subsequent visits
Subsequent Visits
  • Follow-up Consultation Codes are only used to complete the consultation
  • If you are managing all or a portion of the patient’s care, use attending/managing physician codes
time vs complexity
Time vs Complexity
  • How do I decide?
  • Answer: Which ever one best describes the work you did.
major topics24
Major Topics
  • Coding
  • Documentation
  • Reimbursement
  • Medical Record is the primary resource to support codes for physician billing
  • Include all elements that support the selected code
  • If using time, explicitly indicate time taken and what you did during that time.
  • Name of referring physician
  • Reason for the consultation
  • Summary of your findings
  • Recommendations
  • Time spent (code)
  • Counseling/Information Giving
documentation in palliative care
68 year old woman with dyspnea, nausea near the end of her life.

Medical Record by MD:

Feeling a bit better. VS Stable. CPM

Documentation in palliative care
some palliative care domains
Some palliative care domains
  • Patient/Family Unit
  • Physical
  • Psychological
  • Social
  • Spiritual
  • Team
severity of illness intensity of service
Severity of IllnessIntensity of Service
  • Hang Crepe (in the chart)
  • Why is the patient so sick as to require the current setting (and expense)?
  • Why do you need to be there?
documentation pearls
Documentation Pearls
  • Describe the whole picture
  • Describe barriers to plan implementation
  • Clearly state your assessment and plan
    • In my medical judgment
    • In my medical opinion
compare contrast
  • “The patient is a little weaker today, prognosis grim, continue present comfort measures”
compare contrast33
  • Rapid and precipitous decline since last visit. Now bed bound. Cognition is markedly worse. Blood pressure and urine output have declined. Indicates severe organ failure in at least the cardiac, GI, GU, musculoskeletal, and neurological systems.
The wife, 3 daughters, 4 grandchildren and 6 siblings are highly distressed requiring extensive counseling and information giving in the presence of the patient
  • Extensive discussions with nursing, social work and chaplaincy to coordinate care
In my medical judgment, the patient will die in 72-96 hours.
  • It is unwise to move him to another setting.
  • The acuity of need is high. The patient requires around-the-clock RN care and frequent MD visits in order to monitor and respond to changes in condition.
major topics36
Major Topics
  • Coding
  • Documentation
  • Reimbursement
after coding and documentation what next
After coding (and documentation), what next?
  • Coding/Billing Office
  • Payer
  • Review
  • Payment
  • Denial
balance of interests
Balance of Interests
  • Three players
    • Payer

Pay only for needed services

    • Physician (documentation)

Reimbursed for work done

    • Billing/Collection

Get work done and minimize stress

medicare part b
Medicare Part B
  • Regional Carrier
  • Interprets Rules and Instructions
  • Denial of Payment
    • Technical
    • Substantive
  • Adequate documentation
  • Legible
  • “Too busy”
  • “Just want to care for patients”
  • Arrogance
billing office
Billing Office
  • Responds to Threats and Rewards
  • “Get the bills out” vs“Maximize receivables”
  • Relationship with Accounts Receivable
medicare fee schedule
Medicare Fee Schedule
  • Resource-Based Relative Value Scale (RBRVS)
  • (Measure of effort) x (Conversion Factor determined each year)
  • Participating physicians get 80% when they bill Part B
  • Required copayment for participating physicians
  • Nurse practitioners get 85% of what a physician would get
codes and reimbursement
Codes and Reimbursement

Northwestern Faculty Foundation 1995

Northwestern Faculty

burden of appeal
Burden of appeal
  • Physician
  • Track denials
  • Rewards
  • Communicate with payers
palliative care
Palliative Care
  • No special codes (no special rules)
medicare hospice benefit
Medicare Hospice Benefit
  • Attending Physician

Bills Part B in usual fashion

Cannot be associated with the hospice in medical director or hospice medical director capacities (even voluntarily)

Attests to independence

Paper Claim on HCFA 1500 claim form (source of technical denial) or

Electronic Claim (EMC) include HC modifier to CPT code

hospice medicare benefit
Hospice Medicare Benefit
  • Hospice Medical Director

Administrative/supervisory activities included in the per diem rate

Direct Patient Care Services billed fee-for-service to the hospice agency

The hospice agency submits the codes for reimbursement under Part A

medicare hospice benefit53
Medicare Hospice Benefit
  • Physicians Associated with the hospice (even volunteers)

Submit claims to Hospice for submission to Part A

  • Consultants

Submit claims to Hospice for submission to Part A

Requires a contract with the hospice

  • Code for palliative care using standard physician coding
  • Document adequately—hang crepe and clearly state your medical judgment.
  • Reimbursement is influenced by behaviors in billing/accounts receivable department.