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Hospitalist

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Hospitalists often face complications when billing out charges for various encounter specifically in the ER.

The ongoing changes in the healthcare environment have necessitated that a billing team have dedicated and prompt follow through on denials and no claim responses. The range of patient care issues provided by hospitalists is wide and varied. Even though our focus is on medical billing and accounts receivable management, our broad experience across the entire Revenue Cycle Management process for hospitalists is why we can give you an advantage over in-house billing.

Our team at Etransmedia has the knowledge and skills necessary to successfully work denials and provide our Hospitalist clients with valuable feedback to assist in managing and decreasing the most frequently seen denial types, while streamlining revenue and increasing your practice’s collection rates. Getting you paid fast!

What we know…

One of the most common billing errors seen from Hospitalist providers have to do with patients seen in the ER that are either placed in observation by the Hospitalist or placed in observation by a provider other than the Hospitalist:
The Initial observation codes 99218 – 99220 are used only by the provider who admits them into observation: In the event another physician evaluation is necessary, the physician who provides the additional evaluation bills the other outpatient visit codes when they provide services to the patient. (e.g., If  a Surgeon did the Initial Observation and calls in a  Hospitalist, the Hospitalist would bill for a consultation. If the patient has coverage under a Medicare/Medicaid or Managed Medicare/Medicaid insurance plan the codes are:99201-99204 for a new patient     (A new patient is a patient who has not received any E/M or other face to face service within the previous 3 years); or 99211-99215 for an established patient. For all other commercial insurances  Consultation codes 99241-99245 can be used.
Observation Discharge code 99217 cannot be reported on the same day the Initial  codes 99218-99220 are reported. (See Observation Admit/Discharge  Same day codes 99234-99236).
For Medicare, same-day Observation services 99234-99236 require documentation of time in hours, with a minimum of eight hours documented. The CMS Claims Processing Manual (Medicare) indicates that for a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s admitting orders. The observation record should reflect the care the patient receives while in observation, nursing notes, and progress notes prepared by the physician while the patient was in observation status. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.
Observation is a patient status rather than a place.  The observation may take place in the Emergency Department, in a designated observation area of the ED; a formal observation unit or in an inpatient bed.

Below are the sets of Observation codes and the criteria for their use:

  • Observation or Inpatient Care Services (Including Admission and Discharge Services) – Codes when admission to and discharge from observation status all occur on the same day:
99234-Observation or inpatient hospital care for problems of low severity.- Typically 40 mins. spent by bedside & on hospital floor or unit.
– Documentation requires the chief complaint, a detailed or comprehensive history, a detailed or comprehensive exam, and straight forward or low complexity medical decision making.
99235-Observation or inpatient hospital care for problems of moderate severity –Typically 50 mins. spent by bedside & on hospital floor or unit.
– Documentation requires the chief complaint, a comprehensive history, a comprehensive exam, and moderate complexity medical decision making.
99236-Observation or inpatient hospital care for problems of high severity – Typically 55 mins spent by bedside & on hospital floor or unit.
– Documentation requires the chief complaint, a comprehensive history, comprehensive exam, and high complexity medical decision making.
*Note: For Medicare, same-day Observation services 99234-99236 require documentation of time in hours, with a minimum of eight hours documented.
If the patient is admitted and discharged on different days of services, Medicare does not require that the patient stay a minimum number of hours in order to bill for observation services.
  • Initial Observation Care – For patients receiving hospital outpatient observation services who are not subsequently admitted to the hospital as inpatients, physicians should report CPT codes 99217-99220.
99218-Initial observation care, per day, for problems of low severity.- Typically 30 mins. spent by bedside & on hospital floor or unit.
– Documentation requires the chief complaint, a detailed or comprehensive history, a detailed or comprehensive exam, and straight forward or low complexity medical decision making.
99219-Initial observation care, per day, for problems of moderate severity.- Typically 50 mins. spent by bedside & on hospital floor or unit.
– Documentation requires the chief complaint, a comprehensive history, a comprehensive exam, and moderate complexity medical decision making.
99220-Initial observation care, per day  for problems of high severity. – Typically 70 mins. spent by bedside & on hospital floor or unit.
– Documentation requires the chief complaint, a comprehensive history, comprehensive exam, and high complexity medical decision making.
*Note: For stays of less than 8 hours, the initial observation code series 99218-99220 are to be used. In this case, the discharge code 99217 cannot be used since the admission and discharge were on the same date of service.
  • Subsequent Observation Care services provided on dates other than the initial or discharge date.
99224-Subsequent observation care, per day, for stable, recovering, or improving patients. Typically 15 mins. spent by bedside & on hospital floor or unit
99225-Subsequent observation care, per day, for the patient responding inadequately to therapy or has developed a minor complication. Typically 25 mins. spent by bedside & on hospital floor or unit
99226-Subsequent observation care, per day, in which the patient is unstable or has developed a significant complication or a significant new problem. Typically 35 mins. spent by bedside & on hospital floor or unit
*Note: These codes include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status since the last assessment by the physician.
  • Observation Discharge:
99217-Observation care discharge includes services on the date of observation discharge (can only be used on a calendar day other than the initial day of observation).
These services include a final exam, discussion of the observation stay, follow-up instructions, and documentation.
*Note: Do not report 99217 if the patient was placed in observation and discharged on the same day.

 

On October 1, 2016 the Centers for Medicare and Medicaid Services (CMS) will no longer accept unspecified codes in most cases. 

Starting in October, CMS requires greater specificity for claims filed in ICD-10-CM/PCS. The 12-month grace period originally introduced in 2015 said they would not deny claims for lack of ICD-10 specificity. That all changes on October 1, 2016. Payors will most likely follow suit if they haven't already.

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First Pass Clean Claim Rate

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Boost in Revenue*

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Reduction in Cost*

Amazing Result

We’re always on top of all the latest coding and billing updates for Hospitalists. Additionally, to make sure all claims are reimbursed on the first claim submission, our system is able to pre-edit claims prior to the initial submission for possible billing/coding errors. Our detailed end of month reports keep our clients up-to-date on what is happening in their practice so any issues can be addressed quickly. Having an experienced medical billing team, with visibility into performance, is vital to your practice’s financial health.

Although the new industry standards can be confusing and difficult to navigate, our dedicated team here at Etransmedia can assist in guiding you and helping to make your practice grow successfully.

*Please Note: Results are not guaranteed, implicitly or explicitly, and will vary based on several factors such as individual practice demographics, specialty, payer mix, operations, and management among others

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The group at Etransmedia has handled my billing and managed my contracts for more than a decade. They are trustworthy … Read More >
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President, Eastern Woods Radiation Oncology

When my former billing company decided to close abruptly, I contacted Etransmedia to help me set up my own business… Read More >
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Just a note to say ‘thanks’ – having Etransmedia handle the billing was one of the best decisions this Board has ever made … Read More >
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Cumberland Valley Counseling Associates

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