Documentation, CPT codes, modifiers—it’s not glamorous, but it’s an integral part of a 21st-century physician’s job description. The Hospitalist queried more than a handful of billing and coding experts about the advice they would dispense to clinicians navigating the reimbursement maze.

“Physicians often do more than what is reflected in the documentation,” says Barb Pierce, CCS-P, ACS-EM, a national coding consultant based in West Des Moines, Iowa, and CODE-H faculty. “They can’t always bill for everything they do, but they certainly can document and code to obtain the appropriate levels of service.”

Meanwhile, hospitalists have to be careful they aren’t excessive in their billing practices. “The name of the game isn’t just to bill higher,” Pierce adds, “but to make sure that your documentation supports the service being billed, and Medicare is watching. They’re doing a lot of focused audits.”

Some hospitalists might opt for a lower level of service, suspecting they’re less likely to be audited. Other hospitalists might seek reimbursement for more of their time and efforts.

“You have both ends of the spectrum,” says Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education for AAPC, formerly known as the American Academy of Professional Coders. “There are a lot of factors that would go into why a provider would code something incorrectly.”

Here’s how to land somewhere in the middle.

1 Be thorough in documenting the initial hospital visit.

When selecting the level of service for an initial hospital visit, the documentation consists of three key components: history, physical examination, and medical decision-making. The history includes the chief complaint as well as the review of systems. This is “an inventory of the patient’s organ systems.” Both the complaint and the systems review are often incorporated in the history of present illness, says Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist in the Department of Medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

A patient’s family history is commonly overlooked in a hospitalist’s notes, primarily when they know the patient from previous admissions for chronic diseases and when the family history will likely not have an impact on treatment. “If they do not document a complete review of systems or miss one of the histories, the service will definitely be down-coded,” Mulholland says, “no matter how complete the exam and medical decision-making documentation.”

2 Familiarize yourself with Medicare reimbursement rules in the state where you practice.

In some states, Medicare contractors require providers to document the status of each organ system reviewed individually. In other states, it’s acceptable to document a system review with pertinent findings, “whether positive or negative,” and the statement of “all other systems negative,” Mulholland says.

The auditor will give credit for the review based on the number of organ systems documented. “If you miss one system review, it will take down what otherwise would be a Level Three hospital admission to a Level One,” she says. “So there would be a significant financial impact.”

Medicare reimbursement for a Level Three initial visit in Mulholland’s area of practice—Philadelphia County in Pennsylvania—is $206.57, compared with $104.69 for a Level One. During this visit, each of the key components—history, exam, and medical decision-making—need to be documented completely for the provider to receive the highest level of reimbursement.

3 Ask about a patient’s social history.

Social history can be obtained by querying the patient about smoking, drug and alcohol use, his or her occupation, marital status, and type of living arrangement.

“Knowing the social history helps the hospitalist understand the home situation or social circumstances that may have contributed to the hospitalization or may complicate the discharge plan,” Mulholland says.

This is particularly important in decision-making that involves elderly patients. The clinician should “think down the road” as to where the patient will be discharged and if a social worker’s assistance will be needed. It’s about “seeing the whole patient,” she says, “not just the disease.”

4 Remember to include the actual diagnosis.

“As coders, we can see all the clinical indicators of a particular diagnosis,” says Kathryn DeVault, RHIA, CCS, CCS-P, a director at HIM Solutions at the American Health Management Association. However, “unless [physicians] write down the diagnosis, we can’t code it.”

Documents without a diagnosis are more common than one would expect. For example, if a patient has pain when urinating, the hospitalist typically orders a culture. If the result is positive, the hospitalist prescribes an antibiotic for the infection, and too often “the story ends there.” From experience, DeVault can decipher that the patient is being treated for a urinary tract infection, but she can’t assign a code without querying the physician. Hospitalists, she suggests, should try to “close the loop in their documentation.”

5 Be specific in your written assessment of the patient’s condition.

“The main thing that we see is missing documentation,” says Angie Comfort, RHIT, CCS, a director at HIM Solutions. For instance, if a hospitalist documents congestive heart failure, it’s important to indicate whether the condition is chronic or acute and systolic or diastolic.

In the case of a diabetic patient, the notes should specify the type of diabetes. Not doing so “could be a reimbursement-changer,” Comfort says. In contrast, documenting such specifics could result in higher reimbursement, especially if a patient has complications from Type 1 diabetes.

6 Note the severity of the patient’s case.

Hospitalists’ documentation doesn’t always capture everything they’re evaluating for patients. “I’ve seen notes to the extent of ‘patient doing well; waiting on test results,’” the AAPC’s Jimenez says. “If they’re doing certain tests, why are they doing them? What are they trying to diagnose for the patient? What treatment are they considering?”

The reasons for the tests need to be explained. When a provider is monitoring someone in the hospital, the documentation should elaborate on the patient’s response to a treatment, and whether the patient’s condition is better, stable, or worse. This information helps put the severity in perspective.

“A diabetic could be a diabetic out of control. It could be a diabetic who’s not responding or who has comorbidities,” Jimenez says. “No one diagnosis is the same for every patient.”

For an illegible signature, Medicare and the insurance companies have the option of not paying for the service. They’re trying to establish or authenticate who provided the service.

—Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist, department of medicine, University of Pennsylvania, Philadelphia

7 Indicate which aspect of the patient’s condition you are treating.

When multiple providers are involved in a hospitalized patient’s care, it’s important to document your specific role apart from the services rendered by specialists, Jimenez says. The codes billed must be supported by the documentation for each service. Many providers contribute to the inpatient documentation, so it must be clear what each clinician personally performs.

Only report the diagnosis you are treating or the diagnoses that affect the ones you are managing. If a specialist has been brought in to take over treatment for a specific condition, a hospitalist would not bill for that diagnosis code.

There are a lot of factors that would go into why a provider would code something incorrectly.

—Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, director of education, AAPC Salt Lake City

8 Note your personal review of medical records and reports from other clinicians.

Hospitalists should document their review of lab data or radiology reports, discussion of the case with other providers, or collection of the history from someone other than the patient. It’s also helpful to document your personal review of any images, such as a chest X-ray or MRI. Examining the images yourself might lead to higher reimbursement, Mulholland says.

Providers also should note when they request or review old records, and they should include a short synopsis of the information obtained and how it contributed to the current treatment plan.

9 Learn the correct coding for patients being transferred.

A transfer can occur either from a different facility or from a hospital floor to a rehabilitation unit. Either way, the patient is seen twice in one day, with each visit covered by the same hospitalist practice.

“Both physicians often report a separate independent visit. However, because these services occurred on the same day, it is not appropriate to bill for two separate subsequent or initial hospital codes,” says Sherri Dumford, MBA, CHBME, director of operations and past president of the Healthcare Billing and Management Association. “Often what will happen is both services will be reported and get through the billing system. The second claim is just written off as a denied service, when, in fact, you could combine the elements of service of both visits and possibly bill for a single higher level of visit.”

10 Consider delegating to a coding expert.

While smaller hospitalist groups can turn to a coding consultant on an as-needed basis, larger groups might consider bringing a certified coder on staff. This person would inform physicians about proper coding, review their documentation, and “give real-time feedback,” Pierce says.

An internal audit would show if the documentation meets selected evaluation management codes. Also, it usually takes a coding professional to determine whether prolonged services are an option for the team on any given date of service. Someone would need to internally “add together” multiple services on one date to see if there is sufficient time documented to allow billing for these add-on codes, Pierce says. Similarly, critical-care time needs to be accumulated during a date of service.

Physicians often do more than what is reflected in the documentation. They can’t always bill for everything they do, but they certainly can document and code to obtain the appropriate levels of service.

—Barb Pierce, CCS-P, ACS-EM, national coding consultant, West Des Moines, Iowa

11 Indicate the number of minutes spent arranging for a patient’s discharge.

Discharging a patient involves various steps, says Peter Thompson, MD, chief of clinical operations at the Phoenix headquarters of Apogee Physicians, a hospitalist management company that employs about 750 hospitalists across the country. Hospitalists discuss the hospital stay with the patient and family members, prescribe medications, issue discharge recommendations, set up follow-up care, and coordinate with the case manager, specialists, and primary-care physician.

“It generally is one sequential event after the other,” lasting between 20 and 40 minutes and leading up to discharge, Thompson says. Reimbursement for a high-level discharge constitutes more than 30 minutes. However, without proper documentation, he cautions, the claim could be downgraded or denied.

12 Don’t forget to sign, date, and time your progress note.

Last but not least, when it comes to reimbursement, your signature really does matter.

“For an illegible signature, Medicare and the insurance companies have the option of not paying for the service,” Mulholland says. “They’re trying to establish or authenticate who provided the service.”

And they want to know when the hospitalist saw the patient, so it’s a good idea to indicate the exact time of your visit.

Susan Kreimer is a freelance medical writer in New York.

12 Things Hospitalists Need to Know About Billing and Coding