Forum - Questions & Answers

Dec 11th, 2018 - rdinaso    12  1 

Hospitalist and specialist billing E/M on same day

I need all the help I can get on this one. I have many, many situations where a hospitalist bills for a discharge on a day that my neurovascular surgeon bills a subsequent IP visit. Insurance pays on the hospitalist, but denies on my surgeon's E/M. Are others going through the same situation, and if so, how did you resolve it? Both have different group/specialties so I assumed that there would be no problems. TIA!


Dec 20th, 2018 - ChrisW   256  1 

re: Hospitalist and specialist billing E/M on same day

I would appeal, there are times when there is an edit built into the payers claim processing system where this may automatically deny. I did find this information below from CMS. where the "Per Day" may be an issue. It is still worth appealing. The attending should have billed with modifier “-AI” (Principal Physician of Record) indicating they are different physicians as well. I would contact your provider representative to get a copy of the rules the specific payer in question is following to ensure you are correct. Then you have something to back you as well as provider notes if needed. Good Luck - Let us know the outcome.

Pub 100-04 Medicare Claims Processing

B. Two Hospital Visits Same Day
Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.

C. Hospital Visits Same Day But by Different Physicians
In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.

If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.

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