A retrospective study published by the Journal of Hospital Medicine (JHM) identified a more than 50% growth in the adult hospitalist workforce in the US between 2012 and 2019, making hospitalist medicine one of the fastest growing specialties. When it comes to revenue cycle management (RCM), the complexity is much greater for hospitals compared to other healthcare settings. The increased complexity of inpatient care has led hospitalists to rely more heavily on specialized medical billing and coding services. Let’s explore hospitalist billing pain points and how partnering with experts can optimize RCM and reimbursement.
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Common RCM Challenges Hospitalists Face
In essence, billing and coding for hospitalist medicine requires:
- Knowledge of the various subspecialties of internal medicine.
- Comprehensive understanding of codes to report wide range of conditions and related treatments, and the complications that might occur and/or typical comorbidities.
However, several factors make hospital billing and coding complex:
Multiple codes
Hospitalized patients often have multiple, coexisting health conditions, leading to more complex diagnoses. This requires the use of more specific and detailed ICD-10 codes and CPT codes. In addition to these codes for reporting services, hospital billing requires revenue codes. Revenue codes are used on the UB-04 or CMS-1450 form to convey to the payer where the patient was or when they received treatment or what type of equipment was used. There are specific revenue codes to convey if the procedure was performed in an operation theater, emergency room, or another setting.
Reporting both inpatient services and outpatient services
The Centers for Medicare and Medicaid Services (CMS) uses Medicare Severity Diagnosis Related Groups (MS-DRGs) to classify inpatient services for payment under the Inpatient Prospective Payment System (IPPS). MS-DRGs are based on information reported by the hospital, including the patient’s diagnosis, procedures performed, and discharge status. The MS-DRG classification also considers other factors like the patient’s age, sex, and complicating conditions. Moreover, each hospital may follow its own standard protocols. Ensuring compliance with these rules adds to the complexity.
Longer hospital stays
Hospitalized patients typically have longer stays, increasing the volume and complexity of the coding process. Each day’s episodes of care, including tests and interactions with healthcare providers, must be coded accurately. Hospitalized patients are at higher risk for complications and hospital-acquired conditions, which need to be captured through proper documentation and coding.
Specialty services
Inpatient care often involves multiple specialists and departments (e.g., surgery, radiology, pharmacy), each requiring specific codes. Coordinating these codes correctly is essential for accurate billing. Additionally, accurate coding to capture the complexity of the extensive and varied procedures performed in a hospital setting.
Greater risk of complications
Hospitalized patients are at higher risk for complications, which need to be documented and coded accurately. This can include coding for hospital-acquired conditions or secondary diagnoses that emerge during the stay.
Increased documentation requirements
The documentation for hospitalized patients is more extensive, requiring detailed notes from multiple healthcare providers. Coders must assess large amounts of documentation to capture all relevant diagnoses and procedures.
Billing complexity
Billing for inpatient care involves navigating a more intricate set of rules and regulations, including those related to DRGs (Diagnosis-Related Groups), which are used to determine reimbursement for hospital stays. Ensuring compliance with these rules is complex.
Furthermore, hospitals deal with more than 1,300 insurers, according to the American Hospital Association (AHA). Each has different plans and multiple and often unique requirements for hospital bills. Private insurance company payment rates vary widely. Although Medicare has uniform premiums and deductibles, the beneficiary State of residence determines the benefits paid out. Each state also determines how it will reimburse Medicaid recipients. Hospitals also provide uncompensated care, both free care and care for which no payment is made by patients, which the AHA estimates as making up about 6 percent of the average hospital’s costs. Government regulations make hospital billing even more complex (www.aha.org).
Strategies to Navigate Hospital Billing Challenges
Here are some useful strategies that can help hospitalists overcome their medical billing and coding challenges and increase revenue:
- Ensure precise documentation: Hospitalists must maintain accurate and high-quality documentation that clearly reflects the patient’s current condition and care plan. Misrepresenting diagnoses to increase severity for favorable DRG outcomes is fraudulent.
- Code uncertain diagnoses appropriately: For inpatient billing, if a discharge diagnosis is uncertain (e.g., “probable” or “suspected”), it should still be coded as if it existed. Coders should document uncertain diagnoses with definitive signs and symptoms to ensure accurate coding. The American Medical Association highlights common coding errors such as unbundling, upcoding, incorrect use of modifiers, overuse of modifier 22, failing to include documentation for unlisted codes, and neglecting to reference National Correct Coding Initiative (NCCI) edits when reporting multiple codes.
- Report specific diagnosis codes: Physicians should document specific clinical diagnoses, and coders must assign the most specific codes. Reviewing clinical documentation and supporting evidence, such as imaging, helps ensure accurate and specific coding.
- Document medical necessity for diagnostic tests: Ensure compliance with documentation requirements for diagnostic tests, including medical necessity, to avoid overpayments and denials. Properly documented orders minimize the risk of test denials.
- Stay current with inpatient and observation care coding guidelines: Hospitalists need to stay up to date with constantly changing codes and rules. The CPT codes for Initial Hospital Inpatient and Observation Care Services merged in 2023, with code selection based on the patient’s status. There were changes to the evaluation and management (E/M), percutaneous pulmonary artery revascularization, hernia repairs, lab and pathology and COVID-19 vaccination codes. New appendices were added for taxonomy and artificial intelligence and synchronous real-time interactive audio-only telemedicine services.
The updated CPT codes for hospitalists in 2024 include:
99221–99223: Hospital inpatient care services for new or established patients
99231–99233: Subsequent hospital care services
99238–99239: Hospital discharge services
99252–99253: Outpatient consultation services for new or established patients
Other code changes impacting hospitalists include:
- Time-based coding: 99202 requires 15 minutes of total time on the date of the encounter, while 99203 requires 30 minutes. 99306 requires 50 minutes for an initial visit, and 99308 requires 20 minutes for a subsequent visit.
- Hospital outpatient prospective payment system (OPPS): CPT codes 0660T and 0661T are now separately payable under the OPPS, effective April 1, 2024. CPT code 0505T is also paired with HCPCS code C1604, effective January 1, 2024.
- Immunology: New codes 86041–86043 describe acetylcholine receptor (AChR) procedures that include binding, blocking, or modulating antibodies. Code 86366 describes testing for muscle-specific kinase (MuSK) antibodies, and 87593 describes orthopoxvirus testing.
- Vaccine administration: Code 90480 can be used to report the administration of any COVID-19 vaccine for any patient, replacing all previously approved product-specific codes.
- Respiratory syncytial virus (RSV): Five new codes, 90380, 90381, 90678, 90679, and 90683, have been created to report product-specific RSV immunizations.
- Stay updated on payer rules: Continuously monitor and adapt to changes in payer rules and guidelines, especially for high-cost/high-volume services. Regularly check updates from CMS and sign up for notifications from other payers to avoid denials.
Partnering with an experienced medical billing company can make a big difference when it comes to hospital RCM. These companies employ AAPC-certified coders who assess the clinical documentation carefully to assign the diagnosis codes, procedure codes, and modifiers. When documentation is unclear, incomplete, or inconsistent, professional coders will consult with physicians to determine the correct codes, ensuring accurate claims for optimal reimbursement.
Partner with a trusted medical billing company and ensure accurate claims every time.
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