Hospitalists play a crucial role in patient care, especially in inpatient settings.
Hospital medicine practice requires using specific medical codes for billing medical services.
Hospitalists often deal with complex medical conditions requiring detailed documentation, making coding complex.
Keeping up with changes in coding and billing regulations can also take time and effort.
Documenting and coding completely and accurately is key for hospitalists to ensure appropriate reimbursement for their services.
Medical billing outsourcing can make it easier to navigate these complexities and ensure accurate claim submission to ensure optimal payment for services rendered.
Let’s take a look at the key points, including the main challenges and solutions, related to billing hospitalists’ services.
Medical Coding and Billing Challenges for Hospitalists
Accurate documentation and coding are critical for hospitalists, as both under-coding and overloading can lead to audits and affect reimbursement. Hospital billing is inherently more complex than physician billing for several reasons:
- Multiple Billing Codes:
Hospitalist billing requires the use of a wide range of codes, including ICD-10, CPT, and HCPCS codes for diagnoses and procedures, as well as revenue codes.
Revenue codes, used on forms like the UB-04 or CMS-1450, specify where and when treatments occurred or what equipment was used.
Claims must include both valid procedure and revenue codes to be processed accurately.
- Inpatient vs. Outpatient Services:
Billing and coding differ for inpatient and outpatient services, with each setting following distinct guidelines and code sets.
Inpatient services are usually coded based on Medicare Severity-Diagnosis Related Groups (MS-DRGs), with principal and secondary diagnoses and procedures affecting the MS-DRG and reimbursement.
Additionally, hospitals often have internal protocols to follow for accurate coding.
Strategies to Support Accurate Billing of Hospital Services
Understand Evaluation and Management (E/M) codes: Hospitalist billing primarily utilizes Evaluation and Management (E/M) codes specific to hospital settings.
In 2021, the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) implemented new rules for coding E/M office visits.
Report specific diagnosis codes: Physicians should document the most specific diagnosis possible, and coders should assign diagnosis codes to the highest level of specificity.
Specificity in diagnosis coding is critical for proper reimbursement, as payers base payments on detailed, accurate codes.
Coders should also review clinical documentation and supporting data, like imaging reports, to derive more specific codes if needed.
Document medical necessity for diagnostic tests: Hospitalists must ensure that all diagnostic tests are supported by documentation of medical necessity.
This includes maintaining records of test orders, lab results, imaging reports, and case discussions with other providers.
Diagnostic test orders should be properly signed, dated, and include specific diagnoses.
Accurate documentation helps avoid overpayments and minimizes denials from Medicare and other payers.
Stay current with payer rules:
Payer rules frequently change, so hospitalists and billing teams need to stay updated.
CMS regularly updates its guidelines, and other payers often provide notifications through their websites.
Keeping track of policy changes is especially important for high-cost or high-volume services to avoid claim denials.