Chapter 11 Reality Check Billing and Reimbursement

A patient reports to the emergency room with severe RLQ pain. After triaging the patient, examining, and performing diagnostic testing; it was determined the patient had a burst appendix that needed surgery immediately. After the surgery was successfully performed by Dr. Jones, the patient was admitted to the hospital for observation. Dr. Smith admitted the patient, while Dr. Jones performed the surgery. They are both of the same practice. Provider services for inpatient care are billed on a fee-for-service basis. Each physician service results in a unique and separate charge designated by a CPT/HCPCS service procedure code.

Dr. Smith feels it’s appropriate to bill for inpatient services on the same day and Dr. Jones feels he should be able to bill for inpatient services on the same day because he performed the surgery.

Who is correct and why?

The surgeons’ charges are billed according to a global fee/global surgery package which means that one charge covers pre-surgical evaluation and management, initial and subsequent hospital visits, as well as the surgical procedure. How can Dr. Smith and Dr. Jones bill for the same service? Is this legal? Why or why not?

Under what circumstances, if any, could these providers both charge for same day services?

If you were a practice manager, how would you explain this to these two providers who clearly do not seem to understand these rules?v

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