Coding Cues: Answers to your questions about...

November 2, 2007

Two hospital visits in a day; surgical follow-up care; single-system exam

Key Points

Two hospital visits in a day

Sometimes I see a hospital patient in the morning, but her condition deteriorates later in the day and the hospital staff calls my partner to come in for a second visit. Can we bill for both visits in the same day?

That depends. It's inappropriate to bill for separate visits if the patient's being seen the second time in a 24-hour period when the chief complaint is the same and the patient's status hasn't changed. If that's the case, you may combine the work from the second visit with the work from the first if different services have been rendered, and choose the code that best describes both visits. You can bill using either provider's number. But if the patient's condition deteriorates and your partner's called in to see her because of a new problem, it's appropriate to bill a second visit. You may experience a rejection the first time around, but on review, the insurer should pay for both visits. Make sure that your documentation supports the need for the second visit and that you list the new diagnosis code first on the claim.

We started having junior members of our practice assume the follow-up care of our surgical patients. To familiarize themselves with one another, the doctors meet with these patients during the course of their pre-op workup. Should we bill using modifier –54 (surgical care only) or –55 (postoperative management only) because the surgeon doesn't provide the follow-up care?

You shouldn't use either modifier. Typically, when different physicians in a group practice participate in the care of the patient, the group itself bills for the entire global surgical package. The physician who does the surgery submits the service as the performing physician, and the group that employs him submits the claim as the billing provider.

If your group wants to track each doctor's production, you can assign RVUs to the postoperative care, even though this service isn't separately billable within the same group practice.

Single-system exam

I'm trying to improve my documentation. I have some audit tools that tell me I must document examinations in nearly every body system in order to charge a high level of service, regardless of the patient's diagnosis. And because I'm a neurologist, some of my interaction with my patients occurs visually or verbally (Are the patients oriented to the present? Are they suffering apparent memory loss? Can they concentrate?) and I'm uncertain how this might "count" in the documentation process. What's the best way to document this type of visit?

It sounds like you may be relying on a general multisystem exam template to guide your documentation. But the type of exam you're describing is a single-system exam, found in the 1995 and 1997 E&M guidelines. Besides evaluating the higher integrative functions you described, testing cranial nerves, examining sensations and deep tendon reflexes, and testing coordination are all included in a single-system neurological exam. Additionally, this single-system exam also includes elements of a musculoskeletal, cardiovascular, and eye exam. And because observation is part of the exam process in certain areas, you should note that as such in your documentation.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.