American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to bill for hospital patients in transition

From the October 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: How should I bill for evaluating a patient who is in a transitional care unit after being discharged from the hospital? What if I re-admit the patient to the hospital or to a nursing facility?

A: Care provided in a transitional unit is typically considered part of either the discharge or the initial visit at the next facility to which the patient is transferred.

For example, your patient is discharged from the hospital and placed in a transitional care unit so you can monitor her to determine the next step in her care. At the transitional unit, you evaluate her and decide to admit her to a nursing facility. Upon her admission to the nursing facility, you perform a comprehensive nursing facility assessment. You should bill for comprehensive nursing facility assessment only, selecting a level of service that accounts for the complexity of the transitional care unit service (CPT 99301-99303).

If your patient were not admitted to a nursing facility, you would consider the transitional care services part of the initial hospital discharge services.

AMA CPT states that you can bill CPT 99499, unlisted evaluation and management service, if you believe that you provided a separate service in the transitional care unit. However, you need to submit a written report explaining how the service is not captured by an existing CPT code.

If a patient is in a transitional care unit for an extended period, check with the hospital or other facility to see how it classifies its transitional care unit.

Q: How do I code my first visit to a hospitalized patient whom the admitting physician has just transferred to my care?

A: Assuming that the admitting physician billed an initial hospital care code, CPT 99221-99223, for his first encounter with the patient, you must bill subsequent hospital care, CPT 99231-99233, for your first encounter as attending physician. You cannot bill an initial hospital care service because the admitting physician must use those codes.

You can bill a prolonged service with direct (face-to-face) patient contact, CPT 99354-99357, if you spend more time with the patient than is typical for subsequent hospital care. (The evaluation and management [E/M] section of CPT lists typical times for each service.) For the first 30 to 74 minutes you spend with a patient in excess of what is typical, use CPT 99356. For each additional 30-minute period beyond that, use CPT 99357. Prolonged service codes are always reported as "add-ons" to another E/M service.

To illustrate, you perform an expanded problem-focused exam on a hospital patient. The visit requires moderately complex decision-making. Because it is your first encounter with the patient regarding the cause of the admission, you decide to take a comprehensive history. The service entitles you to bill CPT 99232, mid-level subsequent hospital care. However, you spend an hour total with the patient--35 minutes beyond the typical time for a CPT 99232 visit. You can bill CPT 99356 if at least 30 of the additional minutes were spent face-to-face with the patient.

Brett Baker is a third-party payment specialist in the College's Washington office. If you have questions about third-party payment or coding issues, contact him at 202-261-4533 or email: bbaker@mail.acponline.org.

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