Fam Pract Manag. 2017 May-June;24(3):34.

Billing for physicians while credentialing is pending


A new physician in my practice is awaiting credentialing. In the meantime, should he bill as a locum tenens physician?


No. The new physician would have to be working under a contract to provide temporary services in order to bill as a locum tenens physician. A better solution may be to bill incident-to another physician within the group. New physicians may do this while waiting for credentialing as long as all incident-to requirements are met (e.g., they are continuing a treatment plan established at a prior encounter with no changes or new problems addressed and there is direct supervision by the reporting physician). Medicare permits incident-to billing for a physician's services, but private payers may not. You should check with them to be sure.

Defining 24/7 access to care for chronic care management services


Is use of an answering service or patient portal acceptable for providing 24/7 access to care as required for chronic care management services?


Use of an answering service or patient portal must be coordinated to allow for a prompt response to an urgent need. Merely allowing a message to be left for the next business day would not meet the requirement for 24/7 access to care. Medicare and CPT specify that the 24/7 access requirement pertains to care for urgent needs regardless of the time of day or day of week. Medicare's position was described in the final rule for the 2017 Medicare Physician Fee Schedule, which states that care models for providing 24/7 access to care include various contractual relationships between physician practices and other health care providers including telephone triage systems and health information technology such as shared electronic health records and systematic notification procedures. Some or all of these may be used to provide access to urgent care on a 24/7 basis while maintaining information continuity between providers. The keys to meeting the 24/7 access requirement are that the patient or caregiver has a means to make contact with a health care professional for urgent care needs and the physician managing the patient's care is provided information regarding the request and the response to the need for urgent care.

Same-day outpatient and hospital care


How should we bill for this scenario? A patient presents with fatigue and is found to have a hemoglobin of 6. After an hour at my office, the patient is sent to an outpatient clinic for a blood transfusion. The patient needs inpatient care but refuses admission. I spend another half-hour with the patient at the infusion clinic until he agrees to hospitalization. I then see the patient in the hospital for an admission exam and paperwork for another half-hour. I order X-rays and arrange a surgical consult for the following day.


All services on the date of admission must be combined and reported as initial hospital care, according to CPT and Medicare guidelines. Although much of the workup and counseling were provided in the outpatient setting, this work must be included in determining the level of service (likely 99223, depending on the levels of history and examination that were performed and documented). Prolonged service (99356–99357) may be reported if the time spent in each setting is sufficiently documented and the total time goes at least 30 minutes beyond the typical time of the initial hospital care service. Medicare allows only face-to-face time to be counted toward prolonged service in the inpatient setting, not unit/floor time. Discharge day management should be reported only if the physician provides a face-to-face service on that date.

About the Author

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Cindy Hughes is an independent consulting editor....

Author disclosure: no relevant financial affiliations disclosed. Reviewed by the FPM Coding & Documentation Review Panel: Kenneth Beckman, MD, MBA, CPE; Robert H. Bösl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; Emily Hill, PA-C; Joy Newby, LPN, CPC; and Susan Welsh, CPC, MHA.


Send questions and comments to, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.


Copyright © 2017 by the American Academy of Family Physicians.
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