Medicare’s Dedicated Billing Code for Hospitalists – Context and Implications

by | Last updated Jun 14, 2023 | Published on Jul 18, 2016 | Medical Billing

Billing Hospitalists
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Hospitalists are dedicated to providing care to hospitalized patients, but till recently, quality metrics for these specialists had been clubbed with office-based internal medicine or primary care physicians. With the shift from fee-for-service to quality-based payment models, this lack of distinction has proved a major disadvantage for hospitalists. Medicare took an important step this year to resolve this problem with the introduction of a dedicated billing code for hospitalists. This recognition by CMS is seen as confirming the growth of hospital medicine as a unique scope of practice.

Distinct Role of the Hospitalist

There are more that 48,000 practitioners identifying as hospitalists in the U.S., and hospital medicine is the nation’s fastest growing medical specialty. Their services are distinct from their counterparts in primary care or internal medicine in many ways. Hospitalists have expertise in caring for complicated hospitalized patients on a daily basis. Their specialized skills include improving efficiency and safety of care for admitted patients. They may see patients more than once a day and are involved in coordinate care by communicating with the other doctors in the hospital. They also track test results, answer nurses’ questions, provide updates, and handle any issues that may arise. They are also available to communicate with family members.

Reimbursement Issues Facing Hospitalists

Until now, when submitting claims, hospitalists were required follow the same rules as internal medicine, family medicine, or other specialties similar to their daily practice. However, hospitalists face unique challenges in that they treat patients across all age groups and demographics, and most of their patients have serious illnesses. The existing billing model does not provide a way to accurately identify their unique services:

  • Certain quality-based patient satisfaction measures used to evaluate hospitalists under the Medicare Access and CHIP Reauthorization Act (MACRA) relate to the outpatient setting, including waiting room quality and office staff, which are not relevant indicators of their performance.
  • Hospitalists are often penalized incorrectly under Meaningful Use due to complications that occur by observation status and its classification as an outpatient stay.

Relying on benchmarks used for these other specialties and using codes specific to them has therefore led to missed reimbursement opportunities and even unnecessary penalties for hospitalists. By introducing the new code, CMS recognizes that the services that hospitalists provide are distinct and deserve to be reimbursed accordingly.

What the New Billing Code Means

With the growing number of older people and patients presenting with chronic diseases, hospitals are under continuous pressure to manage length of stay and prevent readmissions. Hospitalists play a key role in helping hospitals achieve these goals by ensuring continuity of care to the greatest extent for admissions.

The new billing code for hospitalists has several implications, the most important being that it will enable accurate benchmarking for performance measurement. Hospitalists’ performance will no longer be simply compared to practitioners in the other related specialties. The new code will allow more accurate comparisons which, in turn, will translate to potentially improved reimbursement.

Medical Billing Outsourcing for Accurate and Faster Payments

While using this new code is critical to ensure that hospitalists are assessed and reimbursed properly under the quality-based payment models, delegating medical billing and coding to experts is recommended. Up to date with industry developments, the expert team in a professional medical coding company will use the right codes, review physician documentation for compliance, submit claims accurately, and help hospitalists get the reimbursement they deserve.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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