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Late-Night Admissions by a Resident

March 22nd, 2013 - Seth Canterbury, CPC, ACS-E/M
A resident sees a patient at 10:00 PM on Day 1 and admits the patient to the hospital. The teaching physician sees the patient the following morning on Day 2. Can the resident service from Day 1 be combined with the TP service on Day 2 when billing based on Medicare's teaching physician guidelines? This article answers this question.

Until Medicare released Transmittal 2247 on June 24, 2011 (later replaced by Transmittal 2303 to add additional clarifications), the answer to the above question was made at the contractor level, with some contractors determining that the TP service billed in Day 2 must be based only on the TP's encounter and documentation only, while others allowed combining both services and notes. As of the July 26, 2011 effective date of Transmittal 2247, however, Medicare now has a specific policy regarding this situation.

The transmittal resulted in adding a 4th TP scenario/example to the teaching physician section of Chapter 12 of Medicare's Internet-Only Claims Processing Manual specifically for late-night admissions performed by a resident, which reads:

Scenario 4:
When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day:
·         The teaching physician must document that he/she personally saw the patient and participated in the management of the patient. The teaching physician may reference the resident's note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient's condition has not changed, and the teaching physician agrees with the resident's note.
·         The teaching physician's note must reflect changes in the patient's condition and clinical course that require that the resident's note be amended with further information to address the patient’s condition and course at the time the patient is seen personally by the teaching physician.
·         The teaching physician’s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making regardless of whether the combination of the teaching physician’s and resident’s documentation satisfies criteria for a higher level of service. For payment, the composite of the teaching physician’s entry and the resident’s entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.

Unfortunately,  the clarity that one would have hoped for by the addition of this scenario didn't quite happen. In fact, the wording of Scenario 4 left quite a few (myself included) a bit puzzled. Scenario 3 already addressed a situation where a resident performed the entire E/M service and the TP saw the patient later. It would have seemed to be much easier to simply amend the wording within Scenario 3 to say that its instruction applies even when the delay between the resident's evaluation and the TP's evaluation is more than just a short one, such as when a resident sees a patient late at night on Day 1 and the TP sees them the next morning on Day 2, but that in such a case the service could still be considered one overall E/M with the DOS billed based on that of the TP's evaluation.

Instead, Medicare chose to add this entirely new scenario to the TP E/M section. In this new scenario, they include much wording that is not found in the other scenarios, which gives the false impression that this unique instruction only applies to this scenario, when it doesn't. For example, Medicare says in Scenario 4 that there is no need for the TP to repeat the resident's documentation. But this principle applies to the other scenarios—it's just not written in all of them. They also say that the TP should note any changes in the patient's condition that occur in-between the resident's evaluation and his/her own. But that is also understood for Scenarios 1, 3, and 4—it's just not explicitly stated.
Medicare then adds a sentence that makes it obvious that the DOS used by the TP should be the date he/she sees the patient in cases where the TP evaluation occurs the next morning. Fine. But this sentence also seems to imply that the E/M code billed by the TP should be based only on the TP's personal work. But then how could it mean this? Immediately after this sentence we find the same "standard" ending seen on each of the preceding three TP scenarios, which says that for payment, the composite of the TP's and resident's notes will be used to determine the level. Also, this verbiage also appears in the wording that precedes all of the scenarios, which could be seen as further support that it applies to all of the scenarios about to be discussed in the manual. Because of this, the majority of TP billing experts that I know of are choosing NOT to interpret the sentence referring to the TP's bill reflecting his own "personal" work to mean that we can't combine the TP note with the resident's note in the case of late-night admissions. They are continuing to combine the two notes and bill the initial visit service as of the date of the TP's evaluation of the patient.
That said, Scenario 4 doesn't just refer to the TP repeating only the "key portions" of the E/M service behind the resident, as is specifically mentioned in Scenario 3. It actually doesn't state how much of the visit the TP is expected to repeat, but there is a strong implication (in my personal opinion), that the TP will repeat most, if not the entire, service in these cases since an extended amount of time may have passed since the resident's evaluation on the previous night. Though it is implied from the examples listed for Scenario 3 that the TP will mention any areas of changes or disagreements with the resident's note, this is specifically required for Scenario 4, again likely due to the significant time that may have passed between resident and TP evaluation. It could be argued that the only way for the TP to ensure that he is following Medicare's requirement to note any changes in the patient's condition is that he/she as the TP repeat most, if not all, of the E/M service, though as with other resident/TP scenarios the TP documentation must only touch on key portions provided other findings agree with those of the resident.
So in summary, the TP can bill for an initial service on the date that he/she sees the patient. The code billed by the TP should be an initial visit code. The TP note can still be combined with that of the resident, in spite of wording in one sentence that seems to say otherwise. The TP should probably go ahead and repeat the entire service, but doesn't have to redocument everything. The TP should document, though, his/her performance of at least the key portions of the service, and special care must be taken to address any changes in the patient's condition that may have occurred during the gap between resident evaluation and TP evaluation.

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