Physician Billing

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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

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Major Topics

• Coding
• Documentation
• Reimbursement

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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.

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Coding for physician services

• 2 Codes
• CPT Procedure/Service Code
• ICD-9-CM Diagnosis Code
• Fee
• Physician Fee
• Payers fee schedule
• Permissible co-payment
• Total income reflects payer mix

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CPT Codes

• Current Procedural Terminology
• Source for all physicians, published by AMA
• Evaluation and Management Codes
• (99201-99499)
• History
• Physical Examination
• Decision-making
• Counseling/Information

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Coding by Components

• History
• Limited vs Extensive
• Physical Examination
• Limited vs Extensive
• Decision-making
• Straightforward vs serious

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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

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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
• 630 pm complete.

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Example

• You spend an additional 30 minutes obtaining
  consent, assembling the supplies, performing the
  procedure, and documenting this in the chart.

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Example

• 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.

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Initial Inpatient Consultations (hospital or
nursing home)
Initial Visit Time (min)
99251 20
99252 40
99253 55
99254 80
99255 110
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Prolonged ServiceFace-to-Face
Code Time (min)
Outpatient 99358 99359 Inpatient 99356 99357 30-74 min Ea 30 min 30-74 min Ea 30 min
99257 Ea 30 min



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Case example coding

• CPT E/M Code
• 99255 (110 min)
• 99356 (40 min)
• Diagnosis Code

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ICD-9-CM diagnoses
Diagnosis Code
Anorexia 783.0
Agitation 307.9
Confusion 298.9
Dyspnea 286.6
Pain bone 733.90
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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

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Concurrent Care

• Document care provided
• Use different ICD-9-CM codes

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Concurrent Care Coding Example

• Woman with pulmonary fibrosis, aortic aneurysm,
  dyspnea

Dr. X 99254 Dr. Y 99254
PulmonaryFibrosis Dyspnea 286.6
In addition, CPT Code for paracentesis and ICD-9
code for pleural effusion if it is done by
consultant
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Subsequent Visits

• Follow-up Consultation Codes are only used to
  complete the consultation
• If you are managing all or a portion of the
  patients care, use attending/managing physician
  codes

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Time vs Complexity

• How do I decide?
• Answer Which ever one best describes the work
  you did.

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Major Topics

• Coding
• Documentation
• Reimbursement

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Documentation

• 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.

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Documentation

• Name of referring physician
• Reason for the consultation
• Summary of your findings
• Recommendations
• Time spent (code)
• Counseling/Information Giving

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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

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Some palliative care domains

• Patient/Family Unit
• Physical
• Psychological
• Social
• Spiritual
• Team

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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?

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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

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Compare/Contrast

• The patient is a little weaker today, prognosis
  grim, continue present comfort measures

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Compare/Contrast

• 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.

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• 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

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• 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.

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Major Topics

• Coding
• Documentation
• Reimbursement

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After coding (and documentation), what next?

• Coding/Billing Office
• Payer
• Review
• Payment
• Denial

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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

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Medicare Part B

• Regional Carrier
• Interprets Rules and Instructions
• Denial of Payment
• Technical
• Substantive

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Physician

• Adequate documentation
• Legible
• Too busy
• Just want to care for patients
• Arrogance

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Billing Office

• Responds to Threats and Rewards
• Get the bills out vsMaximize receivables
• Relationship with Accounts Receivable

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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

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Codes and Reimbursement
Code Billed Medicare Allowed
99254 285 145
Nursing Home
99303 190 111
Home
99343 187 112
Northwestern Faculty
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Burden of appeal

• Physician
• Track denials
• Rewards
• Communicate with payers

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Palliative Care

• No special codes (no special rules)

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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

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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

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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

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Conclusions

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

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Do people get better when palliative care is
consulted?

• 36 yo man
• AIDS
• Recurrent pneumothorax

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