SCENARIO 3
You are a nephrologist working at a hospital where all admissions are performed by hospitalists. You get consulted at 3:00 a.m. to come in an perform “emergency dialysis” on one of your group’s Medicare patients on chronic dialysis who has been admitted under observation status. Because you are not personally familiar with the patient, you perform a comprehensive history and a comprehensive physical exam. Although the patient is not critically ill, you provide high complexity medical decision-making in order to decided whether or not your need to call in the dialysis nurse from home to dialyze the patient.

How would you bill for this encounter?

1. Level 5 inpatient consult
2. Level 5 outpatient consult
3. Level 3 initial hospital visit (H&P)
4. Level 5 new office visit
5. You cannot bill anything for your services for this patient

As unbelievable as it sounds, the correct answer is #5.

This is kind of complicated, but the way it works is that kidney doctors are paid a certain amount of money per month to manage patients on dialysis in the outpatient setting. Because of this capitated payment system, you cannot charge Medicare for separate office visits for problems related to dialysis. This makes sense. You wouldn't want physicians double-dipping for reimbursement for the same services.

On the other hand, for inpatient services, nephrologists can charge for patient encounters just like everybody else (admission H&Ps, hospital progress notes, etc.).

Unfortunately, in this example, the patient is technically considered an outpatient (observation patient) so we would have to use the outpatient codes to report the encounter. This means that theoretically, we could use the established office visit codes (similar to the cardiologist in scenario 2), but as stated above, nephrologists are barred from billing office visits for dialysis related problems. This means we can't bill for any E/M service for this patient.

You might ask, "what about billing for the dialysis visit?" Turns out this is not allowed either. For hospital inpatients, nephrologists can indeed bill for dialysis using the 90935 code which pays about $75. Unfortunately, this code can only be used for inpatients, not observation patients (who are considered outpatients).

So, this nephrologist can collect no reimbursement for taking care of this patient in the middle of the night. If you think this scenario sounds like it would be a far-fetched and rare occurence, think again. I was on call last weekend and had it happen twice in one night.