Billing Brilliance: How PM&R Physicians Can Navigate Inpatient Billing Changes with Ease-Billing Brilliance Q & A

Billing Brilliance Q & A
Pdf Summary
Q&A Summary on Billing Practices for PM&R and IM Specialties<br /><br />The document consists of a series of questions and answers about billing processes for Physical Medicine & Rehabilitation (PM&R) and Internal Medicine (IM) professionals. Key points covered include the sharing and utilization of data points across different specialties, interpretation and application of medical decision-making (MDM) guidelines, and specific billing codes and practices for various inpatient settings.<br /><br />**Data Points and Specialty Interaction:**<br />- **Utilization Across Specialties:** When different specialties within the same group practice are truly working independently, they can both utilize the same data towards their evaluation and management (E/M) level.<br />- **Therapy Notes:** Therapy notes from facilities like IRFs can count as data points if they impact the provider's decision-making for that visit.<br />- **Review and Interaction:** Discussions with other specialists (e.g., nephrologists) and reviewing their records count as data points, provided these professionals are not part of the same group practice or specialty.<br /><br />**Management and Billing for Conditions:**<br />- **High-Risk Scenarios:** Conditions like acute CVA (cerebrovascular accidents) less than a week old may be classified as high risk for MDM if they meet criteria for posing a threat to life or bodily function.<br />- **Concurrent Care:** Management of the same condition by multiple providers can lead to billing challenges, particularly with Medicare, which may deny overlaps in care management.<br />- **Drug Management:** Prescriptions must demonstrate evaluation of efficacy and management actions. Terms like "stable" should be supplemented with actions such as "continue current dosing."<br /><br />**Definitions and Clarifications:**<br />- **"External" Providers:** In the inpatient setting, discussions and reviews with external specialists (e.g., different specialty providers) count towards data points, but not when they are within the same specialty or group practice.<br />- **Moderate Subacute Codes:** The complexity guidelines for subacute codes remain the same before and after January 1, 2023; only the calculation approach has changed.<br /><br />**Billing Codes and Procedures:**<br />- **Discharge Policy:** Providers should bill discharge codes on the day the discharge work occurs, even if the patient is not discharged on that exact date.<br />- **Time-Based Billing:** For precise documentation in time-based billing, state exact minutes spent on a case rather than approximations like "greater than X minutes."<br />- **Split/Shared Visits:** CMS guidelines require that one provider must have face-to-face time with the patient, but both providers need not.<br /><br />This information assists healthcare professionals in accurately navigating billing codes and practices, ensuring compliance with AMA and Medicare guidelines. Monitoring updates to coding and payer policies is crucial to maintaining best practices in medical billing.
Keywords
PM&R
Internal Medicine
billing practices
medical decision-making
data points
inpatient settings
high-risk scenarios
concurrent care
drug management
time-based billing