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Medicare - inpatient consult code changes (CR6740) - need help in clarification

Melanie Posted Tue 09th of February, 2010 19:48:35 PM

This site has been absolutely WONDERFUL - perhaps someone can help again:

Here is the scenario:

Patient "A" - is our established patient in our GI-Office

"A" goes to the hospital - is admitted - and our GI doctor is called in for a consult.

Under the new Medicare rule - we cannot bill any of the consult codes because they no longer will be recognized...

BUT - we cannot bill the inpatient initial codes (99221-99223) because we have treated this patient within the last 3 years....

So how the heck are we supposed to bill the initial visit?

SuperCoder Answered Wed 10th of February, 2010 10:33:51 AM

If you look at the CPT manual, the codes 99221 - 99223 are categorized under "Initial Hospital Care", but at the same time there is a sub-heading mentioned under that -- "New or Established Patient". So, please do not assume that these 3 codes are only for new patient, these are actually for an established patient as well. As we are not able to code 99251 due to new Medicare rule, atleast we can pick a code from 99221 - 99223. Do not append AI mod, hence the lack of AI modifier will help to explain that your GI doc is coming for an initial visit at the hospital, but he is not the admitting doc. If the same GI doc comes again to see the same patient in hospital any other day, that time onwards you can code 99231 - 99233 (subsequent visit code).

Melanie Posted Wed 10th of February, 2010 13:43:25 PM

I never assumed anything in my original post nor did I say anything about our patient being new.....
The problem lies with the "Three Year" rule in my original post though....

Melanie Posted Wed 10th of February, 2010 13:44:23 PM

Does the three-year rule apply to inpatient visits when a specialist is called in to review the patient-in-question...

SuperCoder Answered Thu 11th of February, 2010 12:14:38 PM

"Three-year rule" is to distinguish between new and established patient. And there is no "new" or "established" status for inpatients. So in this scenario if the payer is MCR, 99221 - 99223 can be coded and subsequently 99231 - 99233 for further visits under inpatient condition. Private payers may still pay on consult codes.

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