NP/PA visit in the hospital setting

One of our PA's ( our employee) sometimes gets called to see a patient who is at SJH as an outpatient for a transfusion. The physician usually does not submit any billing for this. The PA/NP is called to do a history and physical prior to the transfusion as it is the hospital protocol to have one done by the patient physician before transfusing.

The H & P is medically necessary. These are patients who either came here for a CBC and left before results were back indicating the need for a transfusion, or patients who have a home draw so are not physically present to have a H & P in the office.

How can we capture the E & M that occurs in these hospital outpatient visits?

Also, if the PA sees a patient and does an H & P and signs the notes as Jane Smith, PA dictating for Dr. Jones, who do we bill under, the Dr or the NP/PA?

Example...If a patient is admitted from the ER, NP/PA will see them first and the on-call sees them later in the day. When the NP/PA says "dictating for Dr Jones " it just means that it is Dr Jones' pt. It doesn't always say who the covering admitting physician is. The two visits (MD and NP/PA) are completely separate. NP/PA dictates what the NP/PA did. Even though they discuss the case with an MD (collaborative), that is it. The MD usually comes in eventually the same day and writes a short handwritten note on the progress note section of the medical record.

Does this mean that I need both the NP/PA note and the Dr note? I still wouldn't know who to bill under because if I am understanding correctly there isn't any incident to billing in the inpatient setting either.

OH MAN!! This is so confusing for me and I want to thank all of you for your help/advise in advance!

For the transfusion

I would use the outpatient E&M codes 99212-5 with place of service hospital (like billing an observation visit) and bill with the NPI of whomever did the service- PA or MD.

Editor will address the admission H&P and billing with joint work with MD and PA

Questions

Hospital protocol does not mean you can bill insurance. If the hospital sets protocol, there should be arrangements with the hospital for your services. You need to check into this "arrangement".

In the second scenario, Medicare has "shared visits" in the hospital SOS. To bill under MDs name the MD must also perform a face-face in hospital on same day the NP performs a service. I'm sure codapedia has an article on this to reference.

Maybe You Need to Change The Work Flow On This

In my area, Hem-Onc, many patients have to frequent the hospital for transfusions. If this is the case, smarter practices tell me that a history and physical is dictated (or derived from the EMR) at the beginning of treatment and is updated for latest blood work and is e-mailed or faxed to the hospital unit for use in the outpatient unit. Some hospitals require this submission for every visit; some just require it at the beginning of the "series". This work can be done in the office by by an NPP. If it is necessary for patient care (which it usually is not), a provider visits with the patient on transfusion day and charges the outpatient visit.

Two providers rounding for this service on the same day is expensive and does not make much sense to me.