discharge doding

Hello,
My hospitalist group is frequently consulted on orthopedic patients and we often end up taking over the bulk of patient care including discharging the patient. Can the hospitalist bill a discharge code (99238/9) even though we were originally a consultant?
Note that these are surgical patients where the orthopedist is receiving one global fee for these patients.

Thank you,

Dr. John Hurwitz

sorry..discharge CODING (not doding)

discharge

was there a documented "Transfer" of the patient's care subsequent to the consultation. What condition required the consultation?
The surgeon billing the global surgery is required to include the hospital visits, including discharge, for care related to the surgical procedure.

hospitalist

The surgeon’s packaged payment includes preoperative visits after the decision for surgery is made beginning one day prior to surgery, and postoperative visits by the surgeon related to recovery from surgery, postoperative pain management, and discharge care. The surgeon is entitled to the full global payment if he provides the preoperative, intraoperative, and postoperative management.
If the surgeon relinquishes care and formally transfers the preoperative or postoperative surgical management to another physician not associated with the surgical group, the other physician may bill for his portion of the perioperative surgery management by appending modifier 56 (preop) or 55 (postop) to the procedure code. Unfortunately, the hospitalist is subject to the surgeon’s claim reporting. If the surgeon fails to solely report his intraoperative management (modifier 54 appended to the procedure code), the surgeon receives the full packaged payment. The payor will deny the hospitalist’s claim

from experience...

I always dictated the summary on my post-op patients because I wanted a useful summary of events; the surgeons said "patient had surgery and went home." And I billed for discharge day services and got paid. I also made out the discharge papers, wrote the prescriptions, etc. so in my mind I earned the right to bill for the discharge. The hospitalist could probably code based on time spent and get an equal payment if they fear denial.

Hospitalist coding for discharge services

This is a very common situation. The surgeon performs a procedure with a 10 or more likely 90 day global period. The hospitalist (or patient's own physician) manages the medical care during the stay. Keep in mind that the first visit by the hospitalist is not a consult, per Medicare, because care is transferred for the medical conditions, so the hospitalist may only bill a subsequent hospital visit on the first day of care.

For the SUBSEQUENT HOSPITAL visits, I frequently see the hospitalist addressing post op concerns: diet, pain, discharge planning. The *surgeon* is being paid to do these things. The hospitalists say to me, "Yes, but they don't do it, and the patient needs it done." I'm sure that's true in many cases, but the hospitalist should address the patient's medical conditions, and that is what they can legitimately submit on a claim form, and be paid for.

As for DISCHARGE DAY services, this is clearly part of the surgeon's payment, and the surgeon should pay the hospitalist if they are not going to do it personally. I know, I know. I understand that the discharge document is better if done by the patient's own physician or the hospitalist, but all payers have already paid for that service as part of the global payment, and they should not be asked to pay for it separately.

Will the hospitalist get paid? Yes, but this is one area that I think you have a high chance of being asked to reimburse the money. And, this is an area that I think the RACs can look at easily, and recover money without looking at the medical record. All they would need to do is look for discharge codes after a surgery with a 90 day global period.

Hospitals want this service done for their surgeons, it's good for patients, the internists do a great job of it---but---it is not a separately reimbursable service.

recovery from Surgeon

So: If the surgeon fails to solely report his intraoperative management (modifier 54 appended to the procedure code), the surgeon receives the full packaged payment. The payor denies the hospitalist’s claim ..

Question: then is it industry standard for the payor to recover from the overpaid surgeon ? Or is it more typical that the hospitalist ( whose claim was denied) contact the surgeon based on their documented transfer of care and seek payment for the 8-12% reimbursement from the surgeon?

Recovery from surgeon

The 54 / 55/ 56 modifiers are for surgeons who shared the global package, and are not appropriate for the hospitalist.

You can try to recover from the surgeon. The answer is: tell them to do their own discharge services.

Why get the surgeons pissed off?

[ The answer is: tell them to do their own discharge services]


Or tell the hospitalists to code that day on time 99233- dictating summary is actually quicker than writing a long note and legible, easier to code for the coders at the hospital to capture all comorbidities, more complete for post-hospital caregivers thereby preventing readmissions, able to be sent to the primary care doc therefore pleasing your customer and can end with "25 minutes spent on care at bedside and unit."