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Initial Inpatient Coding

Kim Posted Wed 11th of September, 2019 17:51:42 PM
If a speciality provider does a consultation on a patient admitted to the hospital and it is the first time this provider has seen the patient for this admission, is it appropriate to bill CPTs 99221-99223? There is conflicting information between the CPT book, insurance manuals, and even on this website concerning this issue. We've read that only the admitting physician can bill the initial hospital care codes but the Medicare Claims Processing Manual states "Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT consultation codes (99241 - 99255) prior to January 1, 2010". Please advise on the correct way to code a consultation, specifically for insurances that do not accept consultation codes (99251-99255), by a non-admitting provider. Thank you.
SuperCoder Answered Thu 12th of September, 2019 05:20:22 AM

Hi Kim,

Effective January 1, 2010, CPT consultation codes were no longer recognized for Medicare Part B payment.

In revisions to Consultation Services Payment Policy, it is published that you must code patient evaluation and management visits with E/M codes that represent where the visit occurred and that identify the complexity of the visit performed.

  • Medicare instructed physicians (and qualified NPPs where permitted) billing under the Physician Fee Service (PFS) to use other applicable E/M codes to report the services that could be described by CPT consultation codes.
  • Medicare also provided that, in the inpatient hospital setting, physicians (and qualified NPPs where permitted) who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).

When reporting Initial Hospital Care Service

Medicare is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with CPT consultation codes, for which the minimum key component work and/or medical necessity requirements for CPT codes 99221 through 99223 are not documented.

  • Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.
  • In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.
  • Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
  • Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.

Medicare contractors have been advised to expect changes to physician billing practices accordingly. Contractors will not find fault with providers who report subsequent hospital care codes (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

On the other hand, if your payer is different than Medicare, then you can report consultation codes along with inpatient service.

Hope this helps!

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