Inpatient consultations should be reported using the Initial Hospital Care code (99221-99223) for the initial evaluation, and a Subsequent Hospital Care code (99231-99233) for subsequent visits. In some cases, the service the physician provides may not meet the documentation requirements for the lowest level initial hospital visit (99221).
Full Answer
For an inpatient service, use the initial hospital services codes (99221—99223). If the documentation doesn’t support the lowest level initial hospital care code, use a subsequent hospital care code (99231—99233).
Initial hospital care – E&M codes (99221, 99222, 99223) used to report the first hospital inpatient encounter between the patient and admitting physician. Subsequent inpatient care – E&M codes (99231, 99232, 99233) used to report subsequent hospital visits.
The consultant should report this initial service as an initial inpatient consultation code (99251-99255), with the level determined by the medical necessity of the visit and supported by the documentation guidelines. The initial provider requesting the service will use the consultant’s findings in the ongoing care of the patient.
For an inpatient service, use the initial hospital services codes (99221—99223). If the documentation doesn’t support the lowest level initial hospital care code, use a subsequent hospital care code (99231—99233). Don’t make the mistake of always using subsequent care codes, even if the patient is known to the physician.
The correct inpatient consultation codes for a first evaluation are 99221-99223.
For non-Medicare patients, if the consultation is done after the patient is admitted to the hospital, consultation services may be reported with the inpatient consultation codes (99251– 99255). Consultation services in observation status are reported with the outpatient consultation codes (99241–99245).
CPT 99223 is defined as: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history. A comprehensive exam. Medical decision making of high complexity.
99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity.
The Current Procedural Terminology (CPT®) code 99242 as maintained by American Medical Association, is a medical procedural code under the range - New or Established Patient Office or Other Outpatient Consultation Services.
In the outpatient setting, if the attending physician requests advice or opinion regarding a problem and documents it in the medical record, the consultant physician can use an office consultation code (99241-99245).
CPT code 99232 usually requires documentation to support that the patient is responding inadequately to therapy or has developed a minor complication. Such minor complication might call for careful monitoring of comorbid conditions requiring continuous, active management.
Subsequent observation care, per dayCPT Code Description 99224 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity.
CPT® Code 99241 - New or Established Patient Office or Other Outpatient Consultation Services - Codify by AAPC. CPT. Evaluation and Management Services. Consultation Services. Office or Other Outpatient Consultation Services.
What is CPT Code 99233? CPT code 99233 is assigned to a level 3 hospital subsequent care (follow up) note. 99233 is the highest level of non-critical care daily progress note. When it comes to 99233 documentation is critical, however understanding of the documentation required is even more critical.
Emergency department visit for the evaluation and managementCPT 99281 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making.
In addition to admissions, discharge and daily patient care, hospitalists also perform consultations, prolonged services and bedside procedures, and must bill appropriately for these additional services. Physicians can select the appropriate Current Procedural Terminology (CPT) codes to bill for these services.
request, render and replyFrom this basic process comes the three “R's” of consultation coding: request, render and reply.
In addition to admissions, discharge and daily patient care, hospitalists also perform consultations, prolonged services and bedside procedures, and must bill appropriately for these additional services. Physicians can select the appropriate Current Procedural Terminology (CPT) codes to bill for these services.
A. Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.
The consultant should report this initial service as an initial inpatient consultation code (99251-99255), with the level determined by the medical necessity of the visit and supported by the documentation guidelines.
A consultant may initiate diagnostic and/or therapeutic services at the time of the initial service if they are medically necessary and does not limit the appropriateness of billing a consultation code. A consultation may be reported if the referring physician does not transfer the responsibility of the patient’s care of the specified problem to the receiving physician until after the consultation is complete.
Only one initial inpatient consultation can be reported during a single episode of care. If the consultant is called back for a follow-up service during the same hospitalization or the consultant continues to follow a patient for an identified problem, a consultation code is not appropriate and the follow-up service or subsequent visit should be ...
Documentation guidelines for a consultation service require that all three key components (history, examination, and medical decision-making) be met to support the correct level of consultation. Note: the only variant between a level four and a level five consultation is the medical decision-making component.
The intent of a consultation is for another source to request the physician or NPP’s advice, opinion, guidance, input, or help in making recommendations for evaluation or treatment of a patient as their expertise in a medical area is beyond that of the requestor.
If a physician documents an expanded problem-focused history, comprehensive examination and moderate complexity medical decision-making, the correct code is 99252, as that is the only level where all key criteria are met.
There must be a request from another health care provider documented in the common medical record which indicates the consultant is expected to provide advice and/or opinion. The request must include the need for consultation.
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The Hospital Discharge Day Management services (99238 or 99239) are not to be reported.
Initial hospital care – E&M codes (99221, 99222, 99223) used to report the first hospital inpatient encounter between the patient and admitting physician.
This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.
Hospital Discharge Day Management Services – E&M codes (99238, 99239) used to report the work performed to discharge a patient from an inpatient stay.
Only one hospital discharge day management service is payable per patient per hospital stay.
Service codes 99234 – 99236 are used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service. The codes should be reported in lieu of those described in Part I of this standard. All three (3) “key” components, history, examination and medical decision-making, must be included in the medical record documentation.
Initial Hospital Care may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.
For office and outpatient services, use new and established patient visit codes (99202—99215) , depending on whether the patient is new or established to the physician, following the CPT rule for new and established patient visits. Use these codes for consultations for patients in observation as well, because observation is an outpatient service.
When reporting a consultation code follow CPT rules. The statement that I recommend is “I am seeing this patient at the request of Dr. Patel for my evaluation of new onset a-fib.” At the end of the note, indicate that a copy of the report is being returned to the requesting clinician. In a shared medical record, this can be done electronically.
The advantages to using the consult are codes are twofold: they are not defined as new or established, and may be used for patients the clinician has seen before, if the requirements for a consult are met and they have higher RVUs and payments. Category of code for payers that don’t recognize consult codes.
How will clinicians know if the payer recognizes consults? They won’t know. Most groups suggest that their clinicians continue to select and document consults (when the service is a consult) whether or not they know if the payer recognizes consults or not. They set up an edit in their system so that consult codes can be reviewed and cross walked to the appropriate code, depending on the payer.
For more information on office consults and Medicare consult codes, or to determine proper usage of CPT® codes 99241-99245, become a member of CodingIntel today.
CMS stopped recognizing consult codes in 2010. Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) are still active CPT ® codes, and depending on where you are in the country, are recognized by a payer two, or many payers.
For an inpatient service, use the initial hospital services codes (99221—99223). If the documentation doesn’t support the lowest level initial hospital care code, use a subsequent hospital care code (99231—99233). Don’t make the mistake of always using subsequent care codes, even if the patient is known to the physician.
The admitting physicians can be reported with modifier "AI" for CPT 99221 to 99223 when the patient has "Medicare and Medicare HMO's" insurances since Medicare & HMO's plan would not be covered Consultation services hence Consulting physician can be reported the admit CPT's.
Critical Care Guidelines - CPT 99291 and 99292. - May 25, 2021. Critical care is the direct delivery by a physician (s) or other qualified health care professional of medical care for a critically ill or critically injured patient.
A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. Critical care services include the treatment of vital organ failure or prevention of further life-threatening conditions.
Inpatient consultations should be reported using the Initial Hospital Care code (99221-99223) for the initial evaluation, and a Subsequent Hospital Care code (99231-99233) for subsequent visits. In some cases, the service the physician provides may not meet the documentation requirements for the lowest level initial hospital visit (99221).
When a Medicare patient is admitted, and another physician provides a consultation for that patient, the situation may arise in which both the admitting physician and consulting physician would report an initial inpatient service (e.g., 99221-99223). To differentiate between the two physicians’ services, and to prevent a claims denial for duplication of services, the admitting physician should append modifier AI Principal physician of record to the initial inpatient service code.
But, the endocrinologist would not append modifier AI because he is not the admitting physician overseeing the patient’s overall care. Per CMS guidelines, “In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.”.
Consultation Coding for Medicare. Medicare does not accept claims for either outpatient (99241-99245) or inpatient (99251-99255) consultations, and instead requires that services be billed with the most appropriate (non-consultation) E/M code.
While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code 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.
During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.
initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem (s) and the patient’s and/or family’s needs. Usually, the problem (s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.
The CERT November 2014 forecasting report indicates a projected error rate of 39.8 percent for CPT® code 99223 and a projected error rate of 34.4 percent for CPT code 99233. The data indicates that the specialty of internal medicine is the primary contributor to the CERT error rate: internal medicine error rates are currently trending at 36.6 percent for CPT® code 99233 and 33.3 percent for CPT® code 99223.
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.
Contractors consider only one M.D. or D.O. to be the principal physician of record (sometimes referred to as the admitting physician.) The principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. Only the principal physician of record shall append modifier “-AI” (Principal Physician of Record) in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.
Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.
Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice
If you are admitting, I would use modifier -AI (principle physician of record) if you aren't already. That might help. However, as long as your physician is a separate specialty as the other physician billing initial inpatient care, it should be payable.
Yes, I know. What I'm saying is that with some insurance companies, it doesn't seem to matter - for them, only one physician can bill for initial hospital inpatient. So if claims get denied, use the subsequent codes.
Yes, you are understanding correctly. You would use 99221-99223 or 99218-99220 depending if the admission is IP or Observation respectively. For the IP scenario only you would add modifier AI if your provider was the admitting and/or attending physician who oversees the patient's care, as distinct from other physicians who may be furnishing specialty care.