Coding and Billing for Mobile Medical Care

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Coding and Billing for Mobile Medical Care

• Peter A. Boling, MD
• Professor of Medicine
• Virginia Commonwealth University

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Billable Services

• Visit codes
• Home, Domiciliary Care, Office (2nd site)
• Code selection based on (documented)
• Work
• Time
• Prolonged services
• Care Cert and Re-cert
• Care Plan Oversight
• Ancillaries
• Billing outside of Medicare
• Careful, ABN

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Home Visit vs. Dom Care

• Single residence
• Apartment with kitchenette

• Congregate meals
• On-site services (ALF)

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2007 Medicare Fee Schedule
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2007 Medicare Fee Schedule
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2007 Medicare Fee Schedule
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Domiciliary Care
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Prevalence of Disease

• Unknown (lack of reliable data)
• Moving target due to aging in place
• Many are on downward trajectory
• High prevalence of dementia
• 67 percent in Maryland study
• Functional limitations common

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Models of Care

• Office-based
• Office on site
• Mobile care

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Office on Site

• Contract
• Legal review
• Fair market value for office services
• Billing
• Second site of practice
• Office visit codes
• Staff support
• Nurse from facility available ?
• Sick call model limited hours
• Is this your full-time job?
• 500 - 750 patients ?
• Record keeping

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2007 Medicare Fee Schedule
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2007 Medicare Fee Schedule
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2007 Medicare Fee Schedule
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2007 Medicare Fee ScheduleDomiciliary Care,
Established
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2007 Medicare Fee Schedule
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Mobile Care Model

• No contract needed
• Relationships and marketing are important
• Avoid infringing on other physicians practices
• Consultation vs. primary care
• Best model for less mobile patients
• Both urgent and scheduled visits
• Use of portable diagnostic technology
• Pulse ox
• Lab tests
• Mobile x-ray
• EKG

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A 10-Hour Day
Estimated collections at 80 percent on Medicare
fee schedule
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Days Worked at 812 a day

• 44 weeks (220 days)
• 46 weeks (230 days)
• 48 weeks (240 days)

• 178,640
• 186,760
• 194,880

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ALF Hybrid

• Some mobile patients go to their previously
  established doctors
• Some mobile patients come to scheduled office
  sessions on campus
• Immobile patients are seen in their apartments in
  a timely way

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Necessary Goal for all Mobile Care Providers

• Control the exploding costs of the Medicare
  program (s)
• Part A
• Part B
• Plus C
• Part D

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Medicare Trustees Report to Congress May 1,
2006 page 11
1
1
Hospital trust fund depleted
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Medicare Trustees Report to Congress May 1,
2006 page 19
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Medicare Trustees Report to Congress May 1,
2006 page 17
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GROSS DOMESTIC PRODUCT
2006
Medicare Trustees Report to Congress May 1,
2006 page 25
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History (Trailblazers)
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Exam (Trailblazers)
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Medical Decision Making (Trailblazers)
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Medical Decision Making
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Smith, John 1234567 Date 5-2-07 Start time
215 PM End time 310 PM Pt seen at home due to
inability to walk more than 30 feet
without resting, severe pain, dyspnea CC
increased SOB, leg swelling, urgent visit HPI
Past 3 days felt SOB when lying down, up in chair
all night denies CP, fever, cough, pleurisy
legs more swollen than usual. Felt like hell,
might go to ER today. Skipped Lasix for 4 days
peeing too much, clothes wet. PMH CHF(LVEF
60), HTN, severe OA of hips, knees, diet
DM-II ROS pain 8/10 in knees despite percocet,
constipated, nocturia x 4 (uses jar) Meds see
updated list SH aide inconsistent, usual aide
sick, cant get up to change clothes, lives alone
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Smith, John 1234567 Date 5-2-07 Exam Obese,
in chair, mild distress at rest BP 170/90, P 88,
R 24 T 98.0 Pulse Ox 88 on room air Chest
decreased sounds at bases, crackles CV marked
JVD, regular rhythm, usual 3/6 SEM, 3 edema
below knees Abd NT Neuro alert, non-focal,
baseline cognition A/P Decompensated diastolic
CHF due to non-compliance and social
supports Doubt arrhythmia, ischemia, PE,
infection Chronic arthritic pain Gave lasix 160
mg Refilled pill box Opened to HHA
(Heartfelt) Lab BMP, CBC Return 1 week,
consider knee injection
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Detailed and Comprehensive

• Language in the note care coordination and
  counseling are more than 50 of visit
• Visit time must be charted
• Otherwise bullet counting

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Jones, Judy 9876543 Date 5-2-07 Start time
330 PM End time 400 PM Seen at home due to
bedfast CC sleepy, hard to waken in AM per
caregiver Several times in past month, lethargic
in AM till after breakfast. Sleeps well. No
fever, cough, apparent dysuria or abd. pain.
PMH DM-II, CVA with right plegia/aphasia, HTN,
hyperlipidemia not checking sugars regularly -
glucometer broken ROS limited by aphasia,
caregiver reports no new behaviors other than per
HPI Meds see updated list SH caregiver
concerned, dedicated, has limited education
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Jones, Judy 9876543 Date 5-2-07 Exam In bed,
alert, non-verbal, no distress BP 150/72, P 80, R
14 T 97.0 accuchek 72 Chest decreased
sounds at bases CV regular, no murmur, no
edema Abd soft, NT, active BS Neuro alert,
right side does not move A/P Suspect early AM
hypoglycemia. Consider worsened renal function No
sign of acute abdominal process or infection. BP
controlled. Reduce lantus insulin from 32 to 16
units Phoned order for new glucometer Opened to
HHA (Heartfelt) by TC, see tomorrow Instruct
caregiver re monitoring DM Lab BMP, CBC, UA (did
cath) Return TC 3 days, RV 2 weeks
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Blue, Billy 3456789 Date 5-2-07 Start time
900 AM End time 945 AM Pt seen at apt. due to
dementia, agitated by leaving building to see
doctor CC in ER last week HPI 1 week of
agitation, sent to ER 3 days ago, UTI, rx Bactrim
and meclizine. Staff report no fever, walks
around constantly, looks uncomfortable, more Skin
bruising and blood in urine, fights with other
residents PMH A-fib, BPH, SDAT (1998) ROS
incoherent response Meds see updated list SH
in locked AD unit, good staff support
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Blue, Billy 3456789 Date 5-2-07 Exam Walking
in AD unit, wont sit still BP 130/68, P 66, R
18, T 98.2 Chest clear CV irregular, no
murmur, no edema Abd soft, NT, active BS,
supra-pubic discomfort Neuro non-focal, constant
non-sensical speech, not baseline Skin
ecchymoses on arms A/P UTI, on Bactrim,
possible ADR with warfarin. Delirium. Possible
urinary retention. Rate controlled A-fib Stop
meclizine Hold Bactrim Contact ER for labs
(urine) Lab STAT INR, CBC Return TC 1 day, RV
2 weeks
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Blue, Billy 3456789 Date 5-2-07 Start time
900 AM End time 1015 AM Pt seen at apt. due
to dementia, agitated by leaving building to see
doctor CC in ER last week HPI 1 week of
agitation. Staff report no fever, walks
constantly, looks comfortable, fights with other
residents. Staff and family want him medicated or
sent to psych hospital. No response to prn
risperidone. PMH A-fib, BPH, SDAT (1998) ROS
incoherent response Meds see updated list SH
in locked AD unit, good staff support, no new
staff
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Blue, Billy 3456789 Date 5-2-07 Exam Walking
in AD unit, wont sit still BP 130/68, P 66, R
18, T 98.2 Chest clear CV irregular, no
murmur, no edema Abd soft, NT, active BS Neuro
non-focal, constant non-sensical speech, not
baseline Skin few ecchymoses on
arms A/P Possible delirium. R/O UTI,
depression, unknown environmental effect, stroke.
Rate controlled A-fib Lab INR, CBC, U/A, CS,
BMP Call family Return TC 1 day, RV 1 week
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Additional Services

• Joint and bursa injections
• Wound debridement
• Special tests

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