Inpatient Billing A Brief Overview

1. Inpatient BillingA Brief Overview Joseph Arcuri, MD July 24, 2007

2. GOAL Understand the components that differentiate inpatient from outpatient physician billing.

3. Objectives Describe the factors that differentiate the 3 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. Define concurrent care and how this concept impacts physician billing. Describe the factors that differentiate the 2 levels of billing the day of a patient�s discharge. Define �same day discharge� and the factors that differentiate the 3 levels of billing for this hospitalization.

4. Initial Inpatient Evaluation

5. Subsequent Inpatient Evaluation

6. 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

7. 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.

8. Day of Discharge Reflects time spent coordinating care: < 30 minutes: 99238 > 30 minutes: 99239 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

9. Day of Discharge (cont.) Time spent on day of d/c can include: - evaluation of the patient - discussion with d/c coordinators, SW and with the primary physician - scheduling f/u appointments - direct patient/family education Documentation should include �> 30 minutes spent on education and coordination of care.�

10. Same Day Admit/Discharge Hospitalization of <24 hours 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

11. 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

12. Miscellaneous Billing for time spent with patients on education/counseling (e.g. family conference) 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

13. 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 hospitalized patients. Multiple services treating the same patient for the same condition may not be reimbursed for that condition; typically the primary service loses reimbursement. Only time directly spent by the faculty physician, not time spent by house staff, contributes to billing on day of discharge.

14. Objectives Describe the factors that differentiate the 3 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. Define concurrent care and how this concept impacts physician billing. Describe the factors that differentiate the 2 levels of billing the day of a patient�s discharge. Define �same day discharge� and the factors that differentiate the 3 levels of billing for this hospitalization.