Practice Management

CMS Introduces Billing Code for Hospitalists: What You Need to Know


The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.

The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.

Question: What are the benefits to hospitalists using the code?

Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.

There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.

To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.

Q: When will the new code go into effect?

Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.

Q: What happens to hospitalists if they do not use the code?

Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.

I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.

Q: Where can someone go to find the code? Will it be available on the CMS website?

Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.

As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.

Q: What role did SHM play in bringing this code to fruition?

Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.

Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.

This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!

For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.

Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH

Brett Radler is SHM’s communications coordinator.

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