Fraudulent Billing by Hospitalists?

Jack Percelay writes…

Recently I’ve heard some allegations about fraudulent billing by hospitalists.    I expect this allegation may well relate to inherent inadequacies in current CPT coding. As a pediatric hospitalist working in the PICU, I  am able  to use  daily global codes for patients less than 5 years of age, but such codes aren’t available outside these circumstances.  Maybe they should be……

To me it seems obvious that hospitalists will submit higher level inpatient codes than non-hospitalists, but when I ran my ideas past an adult hospitalist colleague, he wasn’t sure that hospitalists necessarily took care of sicker patients, were more knowledgeable about inpatient coding, and/or routinely got credit for multiple visits per day.   These are the three reasons I believe hospitalists’  CPT coding distribution should be higher than that of PCPs.  In pediatrics we have some data that 40-50 % of codes are level 3, 40-50% level 2, and only 10% or fewer are level 1.  I am not aware of the distribution among adult hospitalists, but think this would be valuable information to share across groups.  My anecdotal observation in pediatrics is that it is easy to fail to chart follow up visits with repeat assessments and discussions that would appropriately raise a visit up a notch.  Most of us are no fan of charting.

Enter global codes.  We are all familiar with the global fees surgeons get for a procedure and the related post-operative management.  One wonders if their typically brief notes are not just a shared personally trait, but also a result of their charting not being audited for reimbursement.  Op notes are detailed.  That’s the proof that the work is done.

Global codes in pediatrics work differently; they are daily global codes, and they are limited to pediatric neonatal and pediatric critical care.  You can check them out under the following numbers in a CPT book:   9946X-9947X.  In general they apply to a calendar day’s service, and are broken down into initial day critical care and subsequent day critical care with some age (and for preemies size > or < 1500g) criteria.  wRVU values are impressive, ranging from  18.46 wRVUs for the first day of neonatal critical care (CPT 99468) to 6.75 wRVUs for subsequent day critical care for a 4 year old  (CPT 99476).  This compares to time-based critical care codes for adults and children >5 years of age where the first 30-74 minutes   (CPT 99291) is worth 5.84 wRVUs and each additional 30 minutes (CPT 99292) is worth 2.92 wRVUs.

Benefits of these codes are that you don’t need to fluff the chart with a 10 item review of systems, nor do you need to document each block of time spent with the patient.  You need to chart what is appropriate for a medical record, not a financial record.  There are of course downsides.  Some kids are much sicker than average, and there is no provision for prolonged face-to-face time with the daily global code.  On the other hand, some kids are less sick.  Overall, it is supposed to average out. 

The codes lack the sophistication of DRGs with 400+ different acuity and resource consumption determinations.  Intensity of work is divided between initial and subsequent days, or stable vs. unstable neonate.

So how were pediatric neonatologists and intensivists successful in developing these codes? Well, it wasn’t easy.  It was a 10-15 year process of submitting audited documentation that care was delivered continuously in a team fashion with supervision by the intensivist, multiple brief visits during the day in addition to the daily rounds, routinely relatively extensive family discussions, and sick patients.  Hmmmmm.   Doesn’t sound all that different to me from how we routinely function on the wards as adult and pediatric hospitalists.

My interpretation of why this happened is that the CPT people recognize that inpatient care delivered in this team mode with 24/7 physician presence warrants global codes.  Politically, it is feasible to introduce these codes for patients < 5 years of age.  Neither CMS nor most subspecialty societies pay much attention to this population.  But, once you try to introduce global codes to general inpatients, it’s a whole other can of worms.  To paraphrase, what’s good for the goslings, isn’t good for the geese.

To come full circle, I still believe we hospitalists can use the current CPT hospital care codes to document the work we do, though I expect we undercode overall.  But I hope when people look at healthcare reform models, some projects will experiment with daily global codes for physician  (and non-physician provider) inpatient care, and other projects will experiment with  global reimbursement for physician/NPP fees for the entire inpatient stay for a particular DRG. 

Feedback? ……Anyone?…… Buehler?

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