For Medicare patients, inpatient consultations are now reported with the initial hospital visit CPT codes 99221–99223 (and not an emergency department [ED] visit code). Providers should consider the following two points in reporting these services. Show
First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. When a patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (i.e., hospital, emergency department, observation status in a hospital, office, nursing facility), all E/M services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. Billing The inpatient care level of service reported by the admitting physician should include the services related to the admission he or she provided in the other sites of service as well as in the inpatient setting. The code selection is based on level of service or time and is considered the first face-to-face service provided to an inpatient. The initial hospital codes (CPT codes 99221–99223) require that all three key components must be met (or exceeded). Do not bill for other related E/M services on same date of admission. This is important to note when adding CPT modifiers 24 and 25 to the claim line. CPT Modifier 24 is used when an unrelated E/M service occurred during a post-operative period of a major or minor surgical procedure (for codes with 10- or 90-day global period). CPT Modifier 25 is used when a significantly, separately identifiable E/M service by the same physician on the same day of the procedure (for codes with 0 or 10-day global period). Different diagnoses are not required. Initial Hospital Visit Codes
CPT code 99222 (50 minutes)
CPT code 99223 (70 minutes)
Documentation In situations where the minimum key component work and/or medical necessity requirements for initial hospital care (CPT codes 99221–99223) services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially meet requirements to be reported for the E/M service. 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. Reporting/billing under these circumstances are deemed to be unusual. In the inpatient hospital setting, all physicians and qualified nonphysician practitioners (where permitted) who perform an initial evaluation visit may bill initial hospital care CPT codes (99221–99223) or nursing facility care CPT codes (99304–99306). Documentation: Overview of Key Components
Note: When billing initial hospital care, all three key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record. Initial Hospital E/M Services (CPT® Codes 99221–99223) Documentation Requirements
Detailed or comprehensive examination — documentation needed:
Medical decision-making that is straightforward or of low complexity — documentation needed (two of three below must be met or exceeded):
99222 — 50 Minutes (average)
Comprehensive examination — documentation needed:
Medical decision-making that is moderate complexity — documentation needed (two of three below must be met or exceeded):
99223 — 70 Minutes (average)
Comprehensive examination — documentation needed:
Medical decision-making that is of high complexity — documentation needed (two of three below must be met or exceeded):
Resources
What are the initial hospital care codes?According to CPT, the initial hospital care codes, 99221–99223, are for “the first hospital inpatient encounter with the patient by the admitting physician.” Initial inpatient encounters by other physicians should be reported with either subsequent hospital care codes (99231–99233) or initial inpatient consultation ...
When coding for initial hospital care how many key components are required quizlet?initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity.
What code is reported for the initial hospital care for a normal newborn infant admitted and discharged on the same date?CPT Code 99463
Code 99463 is reported when the initial hospital assessment and discharge management services for a normal newborn are provided on the same calendar day.
Which of the following codes would be reported for an inpatient hospital encounter?Code 99214 is reported for inpatient services.
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