Health Information Management

Clinic and hospital visit on same date of service

APCs Insider, May 21, 2004

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QUESTION: We have an acute care rural hospital with an ED and multispecialty clinic in the same building. They bill independently with different tax IDs. We do have an urgent care department, but it is owned and operated by the clinic and the physicians are employed by the clinic.

Occasionally a patient comes in to see the physician at the clinic for constipation and he orders cleansing enemas. The clinic does not have the facilities to do this, so the patient is sent over to our medical/surgical unit and hospital nursing staff do cleansing enemas that sometimes take two to three hours. There is no CPT code for this; we can't bill treatment room or supplies.

In the 9-14-01 APCs Weekly Monitor, it states we can bill a low-level E/M for nursing if our E/M documentation guidelines reflect it. This would mean we would have to register the patient on the hospital side. Would this represent double billing?  If we can bill an E/M level on the hospital side, we know we need nursing documentation, but do we need a physician order in the hospital chart? Or if we just have access to the clinic documentation, is that enough? Currently we have separate clinic and hospital charts, but the patient does have a common medical-record number. The patient would be getting a bill from the clinic and one from the hospital for the same date of service. It isn't the patient's fault that the clinic doesn't have the facilities to accommodate this service.
ANSWER: There are three key questions in this narrative:

  • How do you bill an outpatient service that doesn't have a CPT code?
  • Does billing a patient from the hospital for a service for which he or she has just been seen in the clinic represent double billing?
  • Does providing an outpatient service in the hospital require a physician's order? 

In this instance, it is important that the hospital and the clinic be organized as separate legal entities and have separate provider numbers. The following answer would not apply if they  had the same provider number. 
You are correct in stating that it is not the patient's fault that the clinic cannot provide the full service his/her condition requires during the clinic visit. In the rural setting, however, this situation is not uncommon. Often physician or clinic patients must go to the hospital to receive an outpatient service. What makes this case different is that there is no CPT code for the service this patient requires. When a patient receives scheduled outpatient services meeting the definition of an encounter at 42 CFR 410.2 for which no CPT code exists, he or she should be billed an E/M level charge commonly referred to as a visit charge. When the patient has been seen in the clinic on the same day, many payers will deny one of the E/M charges for that day as being duplicate, but this should not discourage you from billing the appropriate E/M charge. The denial may also be affected by what site of service the clinic bills under. 
Although this would appear to be double billing for services, it is not. The E/M charge is designed to cover the cost of the fixed assets, staff, and supplies associated with the patient's care. In your example, these costs occurred in separate locations for separate legal entities. Although it may be inappropriate to purposely split patients' care in order to increase reimbursement, it is not inappropriate to provide services in a second location not available in the first location and bill for both.
All services provided to patients on an outpatient basis require a valid, documented physician's order. Ideally in your situation you would receive a copy of the patient's medical record with physician's order prior for providing services. If the patient medical record is not available at the time of service, it should be requested and placed in the chart. If the physician's order is not available at the time of service, the service should not be provided until an order is received.

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