Blog/ Hospital billing
Rules for billing hospital visits after surgery
Understand the CBHPM rules on medical follow-up after procedures. This article details the ten-day coverage period included in the tier and the rules for billing visits and progress notes separately during a hospital stay
- By
- Rivio, Editorial team
- Published
- Reading time
- 2 minutes
Under the CBHPM (Brazilian Hierarchical Classification of Medical Procedures), the tiers (tiers) assigned to surgical procedures already include the costs of follow-up medical visits and the patient’s immediate postoperative care. In other words, this care is part of the package provided for the surgical procedure and should not be billed separately during this initial period.
However, one relevant point (often overlooked in the billing routine) concerns the period during which this coverage applies. Under CBHPM rules, the postoperative follow-up included in the surgical tier is valid only for the first 10 days after the surgical procedure.
Once this period ends, medical visits are no longer included in the procedure’s tier and can be billed separately, provided there is an actual clinical need. In these cases, billing must follow the correct classification of the care provided:
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Hospital visits: must be billed using code 1.01.02.01-9 when follow-up takes place during a hospital stay.
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Office consultations: must be billed using code 1.01.01.01-2 when the patient’s follow-up takes place on an outpatient basis.
It is essential that the care and billing teams are aligned on this rule, because billing for medical visits or consultations during the first 10 days after the surgical procedure, using specific consultation or visit codes, is not allowed and may result in a denial by the health plan.
A correct understanding of this period prevents billing inconsistencies, reduces the risk of denials and contributes to a more transparent and secure relationship between providers and payers.
