Susan Wu, MD, FAAP, Editor - American Academy of Pediatrics

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Q: Our hospitalist group recently reviewed our collections for the past 18 months. We noticed that we are being reimbursed for our initial inpatient consults, but we have not been getting reimbursed consistently for our daily follow up consults. Any thoughts? A: CMS (Centers for Medicare and Medicaid Services) defines a consultation as a service “provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” 1 CMS requirements for consultation coding are typically referred to as the 3 R’s: 1. 2. 3. BiLLiNG aND CoDiNG CorNer — JAMES O’CALLAGHAN, MD, FAAP, EDITOR A consult must include a request to the consultant by another provider for advice or an opinion. This request can be written or verbal, but must be documented. There must be a reason for the consultation, which also must be documented. Finally, there must be a reply by the consultant, back to the requesting provider, documenting the advice or opinion rendered. If you are getting reimbursed for the initial consult, using CPT initial inpatient consult codes 99251-99255, then I suspect you are successfully meeting CMS guidelines for a consult. Your problem of proper reimbursement for follow up consults could either be a relatively easy fix or might involve a bit more work. In 2006, a major change occurred in the follow up evaluation and management codes. CPT codes 99261-99263, which had represented follow up inpatient consult codes, were deleted. After an initial inpatient consult code, providers are now instructed to use the follow up subsequent hospital visit codes, CPT 99231-99233. Since your decrease in reimbursement for follow up consults occurred at this time, you might be using outdated CPT codes. If this is the case, this is a straightforward fix for your group. However, if your group is using the correct CPT subsequent hospital visit codes, then the solution might be more complex. First, your subsequent follow 18 | American Academy of Pediatrics up days may have been denied based on the content of your follow up notes. An initial hospital consult is expected to address the evaluation and management of a specific problem, including possible or potential future courses of action. Follow up consultation notes can be used to monitor progress and recommend management changes. For example, let us assume that a surgical colleague had consulted you about a child, who is now post-operative day #2 from an appendectomy, for evaluation and management of possible new onset rheumatoid arthritis. In your initial consultation note, you may have recommended a laboratory evaluation, the results of which may not be complete for several days. If your follow up daily consultation notes continually refer to the pending laboratory work up and offer no new management changes, then some insurers might deny payment for those subsequent days. A subsequent hospital visit code could be used once the laboratory evaluation is complete. Second, it may be that you are using an incorrect code on the initial day. Returning again to the CMS definition, a consultation is defined as an opinion or advice. If you are being asked to co-manage a patient, then the initial hospital consultation code could be considered by some insurers, especially Medicare, to be an incorrect code. In Caring for G-tubes? Management of RSV? this case, you are providing concurrent care and a more appropriate code for the first or initial day would be a subsequent hospital day code, CPT 99231-99233. The amount of money by CMS for consultations, thanks in no small part to hospitalists, has skyrocketed in the past few years. CMS is expected to take a closer look at the use of initial consultation codes, beginning in 2008. Coding practices can be complex and can be region-specific, as well as unique to individual insurance providers. Ideally, hospitalists would become familiar with current regional coding practices, or at a minimum each pediatric hospitalist group would have a designated “coding champion.” As always, it is recommended to work closely with local coding professionals. Have a question for the Billing and Coding Corner? Email Dr James O’Callaghan at james.ocallaghan@seattlechildrens.org What’s your focus? We’re looking for writers on these topics and many more. If you’re interested, contact Dr Jennifer Daru at jadaru@gmail.com or Dr Sheldon Berkowitz at Sheldon.Berkowitz@childrensmn.org.
at the CommUNitY hoSPitaL — JOHN, POPE, MD, MHP, FAAP, EDITOR The Combined Pediatric Emergency Department/ Inpatient Unit: 4 Years of Experience Scott D. Krugman, MD, MS, FAAP, Chairman, Department of Pediatrics, scott.krugman@MedStar.net Franklin Square Hospital Center, Baltimore, MD Introduction Community hospitals increasingly depend on pediatric hospitalists to provide care for over six million children hospitalized annually in the United States (2000).1 Community hospitals and their hospitalist programs face significant challenges to providing quality care to children. Seasonal variation of the pediatric inpatient census negatively impacts the retention and quality of pediatric specific staff, and limits the cost effectiveness of maintaining a large dedicated pediatric unit. Community hospitals often admit children to a unit where they are mixed with a population that includes adult patients which has a negative effect on patient satisfaction. Recent data presented at the Pediatric Academic Societies meeting (2007) noted Figure 1: Pediatric Emergency Department (PED) Visit Vo lume by Fiscal Year Number of Visits 26000 24000 22000 20000 18000 16000 14000 12000 10000 FY02 FY03 FY04 FY05 FY06 FY07 Fiscal Ye ar (FY) Combined Unit Opens Figure 1: Pediatric Emergency Department (PED) Visit Volume by Fiscal Year Figure 2: Inpatient Pediatric Admissions by Fiscal Ye ar Number of admissions 900 800 700 600 500 400 300 200 100 0 FY04 FY05 FY06 FY07 Fiscal Year Figure 2: Inpatient Pediatric Admissions by Fiscal Year Figure 4: Combined Pediatric Emergency Department and Inpatient Unit Charges and Payments: Calendar Year 2003 through Fiscal Year 2007 Revenue in dollars that 22% of pediatricians reported their local hospital combined the pediatric unit with an adult service, and 4% completely stopped providing pediatric inpatient care.2 Community hospitals and hospitalist programs develop strategies to remain financially solvent such as having hospitalist s provide new services (caring for nursery babies) or offering services in a new geographic location to increase reimbursements.3 However, this creates challenges for the hospitalist who may struggle with the inefficiency, stress, or inability to cover simultaneous needs of the Emergency Department (ED), inpatient unit, nursery, or another geographic location. Franklin Square Hospital Center (Maryland) opened a combined Pediatric ED/Inpatient Unit in 2004 to address these challenges, and Figure 3: Mean Patient Satisfaction Scores for Inpatient Unit and Pediatric Emergency Department (PED) by Fiscal Year Mean Score $3,500,000 Figure 4: Combined Pediatric Emergency Department and Inpatient Unit Charges and Payments: Calendar Ye ar 2003 through Fiscal Ye ar 2007 $3,000,000 $3,500,000 $2,500,000 $3,000,000 $2,000,000 $2,500,000 $1,500,000 $2,000,000 $1,500,000 $1,000,000 Revenue in dollars 88 86 84 82 80 78 76 74 $1,000,000 $500,000 $500,000 $0 $0 Inpatient Charges Charges Pediatric ED FY04 FY05 FY06 FY07 Figure 3: Mean Patient satisfaction scores for Inpatient Unit and Pediatric Emergency Department (PED) by Fiscal Year Payments Payments CY03 CY03 FY04 FY04 FY05 FY06 FY06 FY07 FY07 Figure 4: combined Pediatric Emergency Department and Inpatient Unit charges and Payments: calendar Year 2003 through Fiscal Year 2007 provide high quality pediatric inpatient care in a community hospital setting with a dedicated pediatric hospitalist program. The Combined Pediatric ED/Inpatient Unit The combined unit has 12 rooms and is physically situated adjacent to the main ED. The unit beds are “flexible” beds that can be utilized as semiprivate pediatric ED beds or inpatient beds. The unit is under the medical direction of a pediatric emergency medicine specialist, but most of the care on the unit is provided by a pediatric hospitalist that sees pediatric ED and inpatients 24 hours per day, 7 days per week. The inpatient service is covered daily by another hospitalist and family practice residents during the daytime with coverage by the hospitalist in the ED after hours. The program is currently looking at additional coverage by a hospitalist in the overlap hours (4 P.M.- 11P.M.). The nursing staff is set at 1-2 “inpatient” nurses and 2-4 “ED” nurses although the exact nursing allocation depends on the daily inpatient census. Outcomes The transition to the combined unit has addressed established challenges to providing inpatient pediatric care in a community hospital, and has measurable positive financial, patient satisfaction, and Figure 5: Length of Stay Comparison for Pediatric Diagnoses CareScience Risk-Adjusted Data: April 2005 to March 2006 Length of stay (days) 3 2.5 2 1.5 1 0.5 0 Asthma (493) Pneumonia (486) Appendicitis (540) Cellulitis (682) Continued on page 23 Franklin Square National Comparison Dehydration (276) Viral Meningitis (047) Croup (464) Pediatric Diagnoses Bronchiolitis (466) Gastroenteritis (008) Influenza (487) Figure 5: Length of stay comparison for Pediatric Diagnoses care science risk- Adjusted Data: April 2005 to March 2006 Hospital Pediatrics | 19
Page 1 and 2: Hospital Pediatrics Issue No. 1 200
Page 3 and 4: Letter from the Chair of Sohm Makin
Page 5 and 6: PraCtiCe ProfiLe — Susan Wu, MD,
Page 7 and 8: for YoUr iNformatioN Opportunities
Page 9 and 10: antibiotic therapy to try to isolat
Page 11 and 12: in length of stay for children trea
Page 13 and 14: In Conclusion The inpatient managem
Page 15 and 16: predischarge bilirubin screening pr
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Page 21 and 22: (Personal communication to Geeta Si
Page 23 and 24: SUBCommittee UPDateS The Combined P

Susan Wu, MD, FAAP, Editor - American Academy of Pediatrics

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