Sourcebook : 9.2 Medicare Payments for Physician Services : 9.2.2 Case Study - Mt. Sinai Hospital

The palliative care team at New York's Mt. Sinai Medical Center provides only consults and works in conjunction with other attending physicians. The team uses the standard CPT (Current Procedural Terminology) billing codes for the first three inpatient palliative care consults, billing all as initial consults; if the physician is the patient's primary attending, the code for initial visits is used. The Mt. Sinai team once estimated that the average cost of a consult was $300, although the mean Medicare payment for such consults, in their experience, was $150.

Physician services to very sick patients in an office, home, or nursing facility follow the same pattern, with a set of E&M codes for each setting, graded by intensity of services and (for some) whether it is an initial evaluation. In the examples given in Table 9.2, "intermediate" is defined as an E&M visit that requires at least two of the following three components which include coordination of care with other providers or agencies:

• Detailed interval history
• Detailed examination
• Medical decision making of moderate complexity

Usually, the presenting problems are of moderate to high severity and require physicians to spend 40 minutes with the patient and the family. The "values" (payments) for the midrange of an intermediate visit (which will be the low end for services to these complex patients) for new and established patients are shown in Table 9.2.

A physician can bill Medicare for the oversight of a care plan if the time that the physician spent organizing care for that patient exceeds 30 minutes (CPT 99375) or 60 minutes (CPT 99376) of their own direct time during one month. The average reimbursement for these services is about $65 for the first 30 minutes.

Fiscal intermediaries have their own "triggers" for reviewing physician records for patterns of overbilling. Intermediaries might look at physicians who often see patients in nursing facilities more than once a week or who usually bill at the "top end" of E&M services. With adequate documentation, the claim should be paid. Physician services to hospice patients (provided that the physician is not an employee of the hospice) are billed exactly the same as they would be for a nonhospice patient. One exception is that the fiscal intermediary must determine whether inpatient hospice care should be billed as a home visit or as a hospital visit, because the two require different E&M codes. Since the HCFA 1500 form does not designate "hospice" as a site of care, it is up to the intermediaries to determine how an inpatient hospice visit should be billed. There is no established practice.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved. For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].