inpatient hospital visit cpt code

CPT code 99221, 99223, 99222 and 99233 – Inpatient hospital visits

by Lori | Feb 9, 2015 | CPT modifiers

99222 : Inpatient hospital visits: Initial and subsequent

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. 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 moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223 : Inpatient hospital visits: Initial and subsequent

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 high 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 high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Payment for Initial Hospital Care Services (Codes 99221 – 99223)

A. Initial Hospital Care From Emergency Room Carriers pay for an initial hospital care service or an initial inpatient consultation if a physician sees his/her patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

B. Initial Hospital Care on Day Following Visit Carriers pay both visits if a patient is seen in the office on one date and admitted to th hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission.

C. Initial Hospital Care and Discharge on Same Day Carriers pay only the initial hospital care code when a patient is admitted as an inpatient and discharged on the same day. They do not pay the hospital discharge management code on the date of admission. Carriers must instruct physicians that they may not bill for both an initial hospital care code and hospital discharge management code on the same date.

D. Physician Services Involving Transfer From One Hospital to Another; Transfer Within Facility to Prospective Payment System (PPS) Exempt Unit of Hospital; Transfer From One Facility to Another Separate Entity Under Same Ownership and/or Part of Same Complex; or Transfer From One Department to Another Within Single Facility Physicians may bill both the hospital discharge management code and an initial hospital care code when the discharge and admission do not occur on the same day if the transfer is between:

1. Different hospitals;

2. Different facilities under common ownership which do not have merged records;

3. Between the acute care hospital and a PPS exempt unit within the same hospital when there are no merged records.

In all other transfer circumstances, the physician should bill only the appropriate level of subsequent hospital care for the date of transfer.

E. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive When a physician performs a visit or consultation that meets the definition of a Level 5 office visit or consultation several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit or consultation that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Carriers pay the office visit as billed and the Level 1 initial hospital care code.

F. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission Physicians use the initial hospital care codes (codes 99221-99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician. Carriers consider only one M.D. or D.O. to be the admitting physician and permit only the admitting physician to use the initial hospital care codes. Physicians that participate in the care of a patient but are not the admitting physician of record should bill the inpatient evaluation and management services codes that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient consultation).

G. Initial Hospital Care and Nursing Facility Visit on Same Day Pay only the initial hospital care code if the patient is admitted to a hospital following a nursing facility visit on the same date by the same physician. Instruct physicians that they may not report a nursing facility service and an initial hospital care service on the same day. Payment for the initial hospital care service includes all work performed by the physician in all sites of service on that date.

B. Requirement for Physician Presence

Physicians may count only the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical time of the visit code billed to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable. In the case of prolonged office services, time spent by office staff with the patient, or time the patient remains unaccompanied in the office cannot be billed. In the case of prolonged hospital services, time spent waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities cannot be billed as prolonged services.

C. Documentation

Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the evaluation and management code billed and to show that the physician personally furnished the time specified in the HCPCS code definition.

Threshold Time to Bill Codes 99221 – 992333

99221 30 60 105 99222 50 80 125 99223 70 100 145 99231 15 45 90 99232 25 55 100 99233 35 65 110

Initial Hospital Care 99221 99222 99223 Time Typically 30 min Typically 50 min Typically 70 min

• Unit/floor time includes:

– Provider present on patient’s hospital unit and at the bedside rendering services to the patient – Reviewing the patient’s chart – Examining the patient

Time Typically 30 min Typically 50 min Typically 70 min g p

– Writing notes/orders

– Communicating with other professionals and the patient’s family on the patient’s floor Inpatient Consults…according to Medicare

• Effective January 1, 2010, the consultation codes are no longg p er recognized for Medicare part B payment

• In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221-99223).

Prepayment review for initial and subsequent hospital evaluation and management services CPT® codes 99223 and 99233

Data Analysis due to the high Comprehensive Error Rate Testing (CERT) error rates for evaluation and management services pertaining to Current Procedural Terminology® (CPT®) codes 99223 (initial hospital visit) and 99233 (subsequent hospital visit). 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.

Documentation requirements

The American Medical Association (AMA) CPT® manual defines code 99223 as follows: 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 high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 an admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital unit. First Coast response on Audit Update

In response to the high percentage of error rates and continual risks of improper payments associated with initial hospital care visits, First Coast will implement a prepayment threshold audit for CPT® code 99223 claims submitted on or after July 25, 2017, and this audit will apply to all provider specialties (with the exception of claims for 99223 for provider specialties 06-Cardiology and 11-Internal Medicine, as there is currently a separate prepayment threshold audit in place for these provider specialties). The new audit will be based on a predetermined percentage of claims in an effort to reduce the error rates for these hospital services.

The AMA CPT® manual defines code 99233 as follows:

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

• A detailed interval history ;

• A detailed examination;

• Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs. Usually, the patient is unstable or has developed a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital unit.

Key points to remember

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.

The key components (elements of service) of evaluation & management (E/M) services are: 1. History 2. Examination 3. Medical decision-making

When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), 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.

Tips pertaining to different types of E/M services can be located by accessing the links in the table below:

CPT code range Type of E/M service 99201-99205 Office or other outpatient E/M services for new patients

99211-99215 Office or other outpatient E/M services for established patients

99221-99223 Initial hospital care E/M services

99231-99233 Subsequent hospital care E/M services

96150-96152, G0425-G0427 Telehealth Services

CPT Code 99223 Inpatient Hospital Care Initial Hospital Care:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

• Comprehensive history • Comprehensive exam • Medical Decision making of HIGH complexity Comprehensive History:

• Chief complaint/reason for admission • Extended history of present illness (HPI) – Extended consists of four or more elements of the HPI • Review of systems directly related to the problem(s) identified in the history of present illness • Medically necessary review of ALL body systems’ history • Medically necessary complete past, family and social history • Four or more elements of the HPI or the status of at least three (3) chronic or inactive conditions, noting that medical necessity is ALWAYS the overarching criterion

HPI – History of Present Illness:

A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include: • Location • Quality • Severity • Timing • Context • Modifying factors • Associated signs/symptoms significantly related to the presenting problem(s)

Chief Complaint:

The Chief Complaint is a concise statement from the patient describing: • The symptom • Problem • Condition • Diagnosis • Physician recommended return, or other factor that is the reason for the encounte

Review of Systems:

An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purpose of Review of Systems the following systems are recognized:

• Constitutional (i.e., fever, weight loss) • Eyes • Ears, Nose, Mouth Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurologic • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

Past, Family, and/or Social History (PFSH):

Consists of a review of the following:

• Past history (patient’s past experiences with illnesses, operations, injuries, and treatments

• Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk)

• Social History (an age appropriate review of past and current activities

Additional Information:

• If patient is admitted to the hospital during an encounter in another setting (i.e. physician office, nursing home, emergency room) and on the same date of service as the admission all E/M services provided by that physician in conjunction with the admission are considered part of the initial hospital care.

• Practitioner’s choosing to use time as the determining factor: – MUST document time in the patient’s medical record – Documentation MUST support in sufficient detail the nature of the counseling – Code selection based on total time of the face-to-face encounter (floor time), the medical record MUST be documented in sufficient detail to justify the code selection • Face-to-face time refers to the time with the physician ONLY. The time spent by other staff is NOT considered in selecting the appropriate level of service

Billing and Coding Guidelines Hospital Visit and Critical Care on Same Day

When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

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.

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

Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.

Initial Hospital Care and Discharge on Same Day

When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT codes 99238 or 99239, shall not be reported for this scenario.

When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 – 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.

When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, Reporting Initial Hospital Care Codes

CMS 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.

Initial Hospital Care Service History and Physical That Is Less Than Comprehensive

Physicians who provide an initial visit to a patient during inpatient hospital care that meets the minimum key component work and/or medical necessity requirements shall report an initial hospital care code (99221-99223). The principal physician of record shall append modifier “-AI” (Principal Physician of Record) to the claim for the initial hospital care code. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.

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.

Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission

In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). 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.

CPT Code 99233 Subsequent Hospital Care Subsequent Hospital Care:

Subsequent hospital care, per day, for the evaluation and management of a patient which requires at least 2 of these 3 key components:

• Detailed interval history • Detailed examination • Medical decision making of HIGH complexity

Detailed Interval History:

• Reason for admission • Problem pertinent review of systems • Extended history of present illness (HPI) – Extended consists of four or more elements of the HPI • Pertinent past family/social history – Directly related to the patient’s problem • Review of the following: – Medical Record – Results of diagnostic tests/studies – Current assessment/status – Changes in patient’s status ▪ Changes in history ▪ Changes in physical or mental status ▪ Response to management/treatment

• Location • Quality • Severity • Timing • Context • Modifying factors • Associated signs/symptoms significantly related to the presenting problem(s)

Review of Systems:

For purpose of Review of Systems the following systems are recognized: • Constitutional (i.e., fever, weight loss) • Eyes • Ears, Nose, Mouth Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurologic • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

• Past history (patient’s past experiences with illnesses, operations, injuries, and treatments) • Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk) • Social History (an age appropriate review of past and current activities)

Medical Decision Making of High Complexity

(Documentaton must meet or exceed 2 of the following 3): • Extensive management options for diagnosis or treatment • Extensive amount of data to be reviewed consisting of the following: – Lab/Diagnostic/Imaging results – Charts/notes from other practitioner’s (i.e. PT, OT, consultants) – Documentation of labs or diagnostics still needed • High risk of complications and/or morbidity or mortality – Comorbidities associated with the presenting problem – Risk(s) of diagnostic procedures(s) performed – Risk(s) associated with possible management options

• Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E/M codes UNLESS their presence significantly increases the complexity of the medical decision making. • Practitioner’s choosing to use time as the determining factor: – MUST document time in the patient’s medical record – Documentation MUST support in sufficient detail the nature of the counseling – Code selection based on total time of the face-to-face encounter (floor time), the medical record MUST be documented in sufficient detail to justify the code selection • Face-to-face time refers to the time with the physician ONLY. The time spent by other staff is NOT considered in selecting the appropriate level of service

Hospital care code billing as as consult code

Policy: Effective January 1, 2010, CPT consultation codes were no longer recognized for Medicare Part B payment. As explained in CR 6740, Transmittal 1875, Revisions to Consultation Services Payment Policy, issued on December 14, 2009, physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. CMS instructed providers billing under the PFS to use other applicable E/M codes to report the services that could be described by CPT consultation codes. CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians where permitted) who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).

CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with CPT consultation codes and for which the minimum key component work and/or medical necessity requirements for CPT codes 99221 through 99223 are not documented. Providers may report CPT code 99221 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. 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 meet requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. Contractors shall expect changes to physician billing practices accordingly. Medicare contractors shall not find fault with providers who report a subsequent hospital care code (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.

The following are edit types that may be applied in the Same Day Same Service Policy.

CCI Definitive: An edit sourced to specific billing guidelines from the General Correct Coding Policies contained in the National Correct Coding Policy Manual published by CMS. For example, the Evaluation and Management Services section (chapter xi) specifically states “A physician should not report an ‘initial’ per diem E&M service with the same type of ‘subsequent’ per diem service on the same date of service.” UnitedHealthcare will not separately reimburse for an initial and a subsequent per diem service on the same date, such as 99223 and 99232.

CMS Definitive : An edit sourced to a specific billing guideline from CMS. For example, the Medicare Claims Processing Manual states “If the same physician who admitted a patient to observation status also admits the patient to inpatient status from observation before the end of the date on which the patient was admitted to observation, pay only an initial hospital visit for the evaluation and management services provided on that date.” UnitedHealthcare will not separately reimburse for an initial observation care service on the same date as an initial hospital care service, such as 99218 and 99222.

Medicaid Billing Guide – INPATIENT HOSPITAL

An inpatient hospital is defined as a facility, other than psychiatric, which primarily provides medically necessary diagnostic, therapeutic (both surgical and nonsurgical) or rehabilitation services to inpatients. Services provided to inpatients include bed and board; nursing and other related services; use of facility; drugs and biologicals; supplies, appliances and equipment; diagnostic, therapeutic and ancillary services; and medical or surgical services. Services of professionals (e.g., physician, oral-maxillofacial surgeon, dental, podiatric, optometric) are not included and must be billed separately. Inpatient hospital services are:

* Ordinarily furnished in a facility for the care and treatment of inpatients.

* Furnished under the direction of a physician (MD or DO) or a dentist.

* Furnished in a facility that is:

* Maintained primarily for the care and treatment of inpatients with disorders other than mental diseases;

* Licensed or formally approved as a hospital by an officially designated authority for State standard-setting; and

* Medicare-certified to provide inpatient services.

An inpatient is an individual who has been admitted to a hospital for bed occupancy with the expectation that he will remain at least overnight, even when it later develops that he can be discharged or is transferred to another hospital and does not use the bed overnight. Days of care provided to a beneficiary are in units of full days, beginning at midnight and ending 24 hours later. Medicaid covers the day of admission but not the day of discharge. If the day of admission and the day of discharge are the same, the day is considered an admission day and counts as one inpatient day.

OUTPATIENT HOSPITAL

An outpatient hospital (OPH) is defined as a portion of a hospital that provides diagnostic, therapeutic(both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require inpatient hospitalization. Outpatient hospital services are:

* Furnished in a facility that is certified as a provider, or as having provider-based status, by Medicare.

To facilitate coordination of benefits, MDHHS follows Medicare’s coverage policies as closely as possible and appropriate. Differences in coverage policy are described in this chapter.

Copayments may be required for inpatient hospital stays, outpatient hospital visits, and non-emergency visits to the Emergency Department for beneficiaries age 21 years and older. Enrollees in the Breast and Cervical Cancer Control Program (BCCCP) are exempt from co-pays. Native American Indians/Alaska Natives are exempt from co-pays consistent with federal regulations at 42 CFR §447.56(a)(1)(x).

The copayments are:

* $50 for the first day of an inpatient stay (applies to DRG or first day per diem payment; copay will not be applied to emergent admissions, transfers between acute care hospitals, from acute care to rehab, or to readmits within 15 days for the same DRG/diagnosis)

* $1 for an outpatient hospital clinic visit

* $3 for non-emergency visit to the Emergency Department Federal regulations at 42 CFR §447.54 specify the cost-sharing requirements for services provided in a hospital emergency department. To impose cost sharing for non-emergency services provided in a hospital emergency department, the hospital must:

* Perform appropriate medical screening under 42 CFR §489.24 Subpart G to determine the individual does not need emergency services.

* Before providing nonemergency services, inform the individual of the amount of cost sharing responsibility for non-emergency service(s).

* Provide the individual with the name and location of an available and accessible alternative nonemergency services provider; determine that the alternative provider can provide services in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the person is otherwise exempt from cost sharing; and provide a referral to coordinate scheduling for treatment with the alternative provider.

Hospitals providing emergency department services are expected to develop cost sharing policies and procedures consistent with the federal requirement.

Payment for Inpatient Hospital Visits – General A.Hospital Visit and Critical Care on Same Day

B.Two Hospital Visits Same Day

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.

C.Hospital Visits Same Day But by Different Physicians

In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.

If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.

D.Visits to Patients in Swing Beds

If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.

Medical Billing Modifier Guide

CPT modifiers update

Key Takeaways:

CPT Code 99222 is used for the initial hospital inpatient or observation care.
It requires a medically appropriate history and/or examination.
A moderate level of medical decision making (MDM) needs to be documented.
For time-based code selection, a minimum of 55 minutes must be spent.
Medicare covers CPT Code 99222.

Overview of CPT Code 99222

CPT Code 99222 is a crucial code used for billing Medicare for initial hospital visits. It represents a moderate level of evaluation and management services provided to patients during their hospital stay. To ensure proper reimbursement for CPT Code 99222, healthcare providers must adhere to specific documentation requirements.

Accurate documentation plays a vital role in claiming reimbursement for CPT Code 99222. Healthcare providers must document a medically appropriate history and/or examination, along with a moderate level of medical decision making (MDM). Proper documentation is essential to demonstrate the patient’s condition and the services provided, ensuring accurate billing and reimbursement.

To further understand the importance of documentation for CPT Code 99222, let’s delve into the specific requirements and guidelines.

Documentation Guidelines for CPT Code 99222

The documentation requirements for CPT Code 99222 are crucial for accurate billing and reimbursement purposes. It is important for healthcare providers to understand and adhere to these guidelines to ensure proper documentation. The requirements include a medically appropriate history and/or examination and a moderate level of medical decision making (MDM).

For a medically appropriate history and/or examination, healthcare providers should document the patient’s chief complaint, medical history, relevant physical findings, and any other pertinent information. This documentation should be thorough and comprehensive, providing a clear picture of the patient’s condition and the services provided.

In addition to a medically appropriate history and/or examination, a moderate level of MDM must be documented. This includes assessing the complexity of the patient’s problems, the amount and complexity of data reviewed and analyzed, and the risk of complications or morbidity associated with the patient’s management.

Healthcare providers should familiarize themselves with the criteria and guidelines for documenting CPT Code 99222 to ensure that all necessary elements are included in the documentation. By following these guidelines, healthcare providers can accurately bill and report CPT Code 99222, leading to proper reimbursement and compliance with coding standards.

Proper documentation not only ensures accurate billing but also supports the quality of care provided to patients. It provides a comprehensive record of the patient’s condition, assists in continuity of care, and facilitates effective communication among healthcare providers.

Reimbursement for CPT Code 99222

The reimbursement for CPT Code 99222 can vary based on several factors, such as the payer, location, and complexity of the patient’s condition. While Medicare typically reimburses at a set rate for CPT Code 99222, private insurance companies may have their own reimbursement rates.

To ensure proper reimbursement for CPT Code 99222, healthcare providers must submit accurate and detailed medical billing claims. Proper documentation of the services provided, including a medically appropriate history and/or examination and a moderate level of medical decision making (MDM) or time spent, is essential.

Working with a reputable medical billing company, like Medical Bill Gurus, can greatly enhance the reimbursement process. Their expertise and experience in medical billing can help ensure that claims are submitted correctly, maximizing reimbursement for healthcare providers.

Benefits of Working with Medical Bill Gurus

Expertise in medical billing and coding
Accurate submission of medical billing claims
Maximized reimbursement for CPT Code 99222
Efficient handling of the billing process
Assistance with navigating payer requirements

Time Spent for CPT Code 99222

If the code selection for CPT Code 99222 is based on total time spent, the healthcare provider must spend a minimum of 55 minutes with the patient. This time includes both face-to-face time and non-face-to-face time spent on the patient’s care. It is important to accurately document and track the time spent to support the use of this code. Only time spent on the date of the encounter can be considered towards the minimum time requirement for CPT Code 99222.

Medical Bill Gurus: Your Medical Billing Partner

At Medical Bill Gurus, we are dedicated to providing exceptional medical billing services to healthcare providers. Our team of experts specializes in handling all aspects of healthcare billing, including the complex world of insurance payers and Medicare billing. We understand the challenges that healthcare providers face when it comes to accurate and timely reimbursement.

With our extensive experience in medical billing, we can help you navigate the intricate processes involved in billing for CPT Code 99222 and other medical billing codes. We ensure that your claims are submitted correctly, maximizing your reimbursement potential. Our comprehensive knowledge of healthcare billing regulations and requirements allows us to streamline the billing process, saving you time and effort.

As your medical billing partner, we are committed to ensuring accurate and timely payment for your services. We stay up-to-date with the latest changes in healthcare billing guidelines and regulations, including those specific to insurance payers and Medicare. Our expertise enables us to optimize your revenue cycle, minimizing claim denials and ensuring smooth cash flow.

When you choose Medical Bill Gurus for your medical billing needs, you can expect the highest level of professionalism and efficiency. We prioritize accuracy and compliance in all our billing processes, adhering to industry best practices and standards. Our goal is to ease your administrative burden and help you focus on providing quality patient care.

Contact Medical Bill Gurus at 1-800-674-7836 to discuss how we can assist you with your medical billing needs. Let us be your trusted partner in maximizing your reimbursement and ensuring the financial success of your healthcare practice.

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Understanding Articles by Medicare Administrative Contractors (MACs)

Medicare Administrative Contractors (MACs) play a significant role in providing coding and billing guidelines for Medicare services. They publish various types of articles that offer valuable insights and instructions for healthcare providers. These articles are designed to ensure accurate billing and coding practices. Let’s explore the different types of articles published by MACs:

Billing and Coding Articles

Billing and coding articles are essential resources that provide guidance on the correct procedures for submitting claims and coding for Medicare services. These articles help healthcare providers understand the specific requirements outlined in the Local Coverage Determination (LCD) and enable them to accurately bill Medicare for their services.

LCD Reference Articles

MACs also publish LCD reference articles that provide additional information and support for the LCDs. These articles offer comprehensive explanations and clarifications that help healthcare providers comply with the LCD guidelines and submit claims effectively.

Response to Comment Articles

During the Proposed LCD comment period, external stakeholders often raise questions or concerns. In response, MACs publish comment articles addressing these issues. These articles aim to provide clarification and address any doubts or queries that arise from the comments received.

Self-administered Drug Exclusion List Articles

MACs also release self-administered drug exclusion list articles that specify the drugs excluded from coverage under Medicare. These articles inform healthcare providers about the specific medications that fall under this exclusion and help them understand the billing and coverage implications associated with these drugs.

Draft Articles

When a new LCD is proposed, MACs publish draft articles in support of the proposed LCD before it becomes a final LCD. These articles provide insights into the proposed changes and offer healthcare providers an early understanding of the forthcoming guidelines. This enables them to prepare for the implementation of these changes and revise their coding and billing practices accordingly.

Understanding the articles published by Medicare Administrative Contractors (MACs) is crucial for healthcare providers. These articles serve as valuable resources, offering guidance on billing and coding, LCD references, responses to comments, self-administered drug exclusions, and draft LCDs. By staying informed and following these guidelines, healthcare providers can ensure accurate billing and coding practices, leading to efficient reimbursement for their services.

Changes in E/M Documentation Guidelines for Hospital Visits

The evaluation and management (E/M) documentation guidelines have recently been updated, leading to changes in how hospital visits, including inpatient visits and consultation visits, are documented and coded. These guidelines now emphasize the importance of a medically appropriate history and examination in determining the level of E/M code for hospital visits. Specifically, for CPT Code 99222, it is no longer necessary to provide a comprehensive history and examination. Instead, the code selection is based on the medical decision-making (MDM) or total physician time spent during the encounter.

This shift in documentation guidelines allows healthcare providers more flexibility in determining the appropriate E/M code for hospital visits. With a focus on MDM or total time spent, providers can accurately reflect the complexity of the patient’s condition and the level of care provided, resulting in more accurate coding and billing.

Comparison of E/M Documentation Guidelines:

These changes in the E/M documentation guidelines for hospital visits aim to streamline the coding process and accurately reflect the complexity of the care provided. By focusing on the medical decision-making process or total physician time, healthcare providers can ensure that the level of service is appropriately documented, leading to more accurate coding, billing, and reimbursement.

Inpatient Hospital Visits: CPT Codes 99221-99223

For Medicare Part B patients and payers that no longer accept consultation codes, inpatient hospital visits are now reported using CPT codes 99221-99223. These new codes replace the previous consultation codes 99251-99255. It is important to understand and accurately use these codes to ensure proper billing and reimbursement.

To differentiate between multiple providers reporting inpatient hospital visits on the same day, the admitting physician appends modifier -AI. This modifier indicates the principal physician of record for the visit.

The CPT codes 99221-99223 represent different levels of initial hospital inpatient or observation care. The appropriate code should be selected based on the documentation of the visit and the level of medical decision making (MDM) or time spent.

Overview of CPT Codes 99221-99223

When reporting inpatient hospital visits with CPT codes 99221-99223, each code represents a different level of care provided to the patient.

These codes should be chosen based on the documentation and level of medical decision making (MDM) and time spent during the visit. Accurate documentation is vital to support the appropriate code selection and ensure appropriate reimbursement.

By using the correct CPT codes 99221-99223 and appending the modifier -AI when necessary, healthcare providers can accurately report inpatient hospital visits and receive appropriate reimbursement for their services.

Office Consultations and CPT Codes 99242-99245

When it comes to office consultations, it’s important to be aware that Medicare Part B does not cover these services. However, there are still some payers who accept CPT codes 99242-99245 for office consultations. The lowest level consultation code, 99241, has been deleted, leaving the remaining codes available for selection based on the level of medical decision making (MDM) or total physician time spent.

These codes, namely 99242-99245, represent different levels of complexity and time spent during an office consultation. By accurately documenting the services provided, healthcare providers can ensure appropriate coding and billing for these consultations.

If you’re unsure about the specific requirements for each code, it’s essential to refer to the official CPT code guidelines to ensure compliance and accurate documentation. By doing so, you can effectively capture the complexity of the consultation and provide the required information for proper reimbursement.

Components of Medical Decision Making (MDM) for E/M Services

Medical Decision Making (MDM) plays a crucial role in determining the appropriate level of E/M services. It consists of three key components that healthcare providers must consider:

The number and/or complexity of problems addressed at the encounter.
The amount and/or complexity of data reviewed and analyzed.
The risk of complications and/or morbidity or mortality of patient management.

To select the correct level of E/M services, at least two of these components must have the same level of complexity, which can range from straightforward to high. Understanding the components of MDM is vital for accurate documentation and coding, ensuring that healthcare providers are properly reimbursed for their services.

Prolonged Services and CPT Code 99418

Prolonged services are an important aspect of healthcare billing when the time spent on inpatient or observation services exceeds the established time limit by at least 15 minutes. To accurately report and document these services, healthcare providers rely on CPT Code 99418, which is specifically designed for reporting prolonged services.

CPT Code 99418 is billed in addition to the highest level of the Evaluation and Management (E/M) family of codes for hospital services. It allows healthcare providers to capture the additional time spent in providing care beyond what is typically expected for a particular service.

This code, CPT Code 99418, replaces the previous codes for reporting prolonged services, namely 99354-99357. By streamlining and simplifying the reporting process, CPT Code 99418 ensures accurate documentation and billing for prolonged services.

For healthcare providers working with Medicare Part B patients, it is important to note that HCPCS code G0316 should be used instead of CPT code 99418 for reporting inpatient or observation prolonged services.

Comparison Table: CPT Code 99418 vs. Previous Prolonged Service Codes

Table: Comparison of CPT Code 99418 with Previous Prolonged Service Codes

By utilizing CPT Code 99418 and accurately documenting prolonged services, healthcare providers can ensure that their services are appropriately recognized, billed, and reimbursed. It is essential to stay updated with the latest coding guidelines and guidelines provided by Medicare and other payers to ensure compliant and efficient billing processes.

Understanding CPT Code 99222 is crucial for healthcare providers to ensure accurate billing and reimbursement for initial hospital visits. Meeting the documentation requirements, including a medically appropriate history and/or examination, is essential. Additionally, healthcare providers must demonstrate a moderate level of medical decision making (MDM) or meet the minimum time spent requirement.

Reimbursement for CPT Code 99222 varies depending on factors such as the payer and the complexity of the patient’s condition. It is important for healthcare providers to familiarize themselves with the reimbursement guidelines of different payers to optimize their revenue. To navigate the complexities of medical billing and maximize reimbursement, healthcare providers can rely on the expertise of medical billing companies like Medical Bill Gurus.

Medical Bill Gurus specializes in healthcare billing services and can provide comprehensive support in all aspects of medical billing, including accurate coding and claim submission for CPT Code 99222. Working with Medical Bill Gurus ensures that healthcare providers can focus on patient care while professionals handle their medical billing needs. Contact Medical Bill Gurus at 1-800-674-7836 to discuss your medical billing requirements and optimize your reimbursement for CPT Code 99222.

What is CPT Code 99222 used for?

CPT Code 99222 is used to report the initial hospital inpatient or observation care for the evaluation and management of a patient.

What documentation requirements must be met for CPT Code 99222?

The documentation requirements for CPT Code 99222 include a medically appropriate history and/or examination and a moderate level of medical decision making (MDM) or time spent.

How is CPT Code 99222 reimbursed?

Reimbursement for CPT Code 99222 varies depending on factors such as the payer and the complexity of the patient’s condition.

How much time must be spent for CPT Code 99222?

If code selection is based on total time spent, a minimum of 55 minutes must be met or exceeded.

What is Medical Bill Gurus?

Medical Bill Gurus is a professional medical billing company that specializes in healthcare billing services.

What articles do Medicare Administrative Contractors (MACs) publish?

Medicare Administrative Contractors (MACs) publish billing and coding articles, LCD reference articles, response to comment articles, self-administered drug exclusion list articles, and draft articles.

What are the changes in E/M documentation guidelines for hospital visits?

The changes in E/M documentation guidelines for hospital visits require documentation of a medically appropriate history and examination, with the level of E/M code determined by the medical decision making (MDM) or total physician time on the date of the encounter.

What are the CPT codes for inpatient hospital visits?

Inpatient hospital visits are reported using CPT codes 99221-99223 for Medicare Part B patients and payers that no longer accept consultation codes.

What are the CPT codes for office consultations?

Office consultations are reported using CPT codes 99242-99245, which are selected based on the level of medical decision making (MDM) or total physician time.

What are the components of medical decision making (MDM) for E/M services?

The components of medical decision making (MDM) for E/M services are the number and/or complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.

How are prolonged services reported?

Prolonged services are reported using CPT Code 99418 when the time spent on inpatient or observation services exceeds the time limit by at least 15 minutes.

What is the conclusion for understanding CPT Code 99222?

Understanding CPT Code 99222 is essential for accurate billing and reimbursement of initial hospital visits.

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Coding for consults and readmissions

ICD-9 coding tips for consults and readmissions, with modifiers for subsequent visits to multiple physicians

Published in the September 2010 issue of Today’s Hospitalist

CONFUSED ABOUT HOW TO CODE a readmission or whether to wait until a patient is discharged to bill for your services? Questions on coding for consults and readmissions are just two of the questions I’ve received this month from readers. Read on for my advice.

Today’s Hospitalist’s Coding articles provide hospitalist physicians the practical tips they need to thoroughly document their services and maximize their reimbursements.

Readmissions I am wondering how to bill a patient’s readmission. The patient was discharged in the morning but readmitted that afternoon. Which services should we bill for the discharge and then the admission when they both occur on the same calendar date?

If the patient returned with the same condition, I recommend avoiding the discharge and admit codes. Instead, combine both levels of service in a subsequent visit code (99231-99233) based on the level of history, exam and medical decision-making.

If the patient had an entirely new condition that caused the new admit, then follow through with a whole new H&P work-up and bill the initial hospital visit code (99221-99223), as well as for discharge services earlier that day. Payers won’t be happy seeing a discharge and an admit on the same day, but if you submit the appropriate documentation showing that the patient needed to be admitted for a new diagnosis, you should avoid being hassled (or denied).

When to bill? Should hospitalists bill their portion of a hospitalization when we see the patient, or should we wait until the patient is discharged?

Either way works. Some groups hold billing until the hospital stay is completed, especially if patients stay a week or less. For longer hospitalizations, you may want to bill for services already completed so you don’t hold up the reimbursement process.

Hospitalist codes Is there a source that shows the most common codes that hospitalists use?

I haven’t seen any source document that specifically lists them. However, here are the CPT codes that, in my experience, hospitalist groups use most frequently:

Initial hospital visits (99221-99223)
Subsequent hospital visits (99231-99233)
Discharge services (99238-99239)
Critical care services (99291-99292)
Inpatient consultations (for non-Medicare patients) (99251-99255)

Working with residents Say a patient is admitted at 10 p.m., when the resident team sees the patient, writes an H&P and does all the orders. I see the patient the next day, review the resident note and H&P, make corrections where appropriate, and independently (and personally) perform key portions of the H&P myself. Do I submit my charges as an initial visit on the day I see the patient, or use a subsequent visit code? I know I can’t bill for services on a day when I don’t see the patient, but I want to be reimbursed for the H&P I do.

Submit the H&P as an initial visit (99221-99223) on the day you see the patient under your name and number.

Consultations We often debate how to code for a consultation requested by a surgeon following a patient’s inpatient surgery. One of the physicians from our team performed the patient’s outpatient H&P medical clearance within seven days of the patient’s surgery.

We code that H&P with an outpatient consultation code (99241-99245) unless it’s a Medicare patient. For visiting the patient after the surgery, should we use inpatient consult codes (99251-99255) “unless it’s a Medicare patient, in which case we’d use subsequent visit codes? Or should we just use inpatient subsequent visit codes for all patients because we do have the H&P dictation available?

2021 readmission resources from CMS

To code visits after an inpatient surgery, use the subsequent visit codes (99231-99233), even for patients not covered by Medicare.

Using the -25 modifier I am writing about one of your replies in the March 2010 column ( “Uncompleted procedures? Here’s how to bill.” ). The question was how to bill for both critical care services and a subsequent visit on the same day for the same patient seen by two different physicians within the same group.

You claimed that the group should use the modifier -25 with the subsequent visit E/M service code to signal the fact that it was a separately identifiable service. However, that contradicts the AMA’s definition of modifier -25, which states the following:

“Significant, separately, identifiable evaluation and management service by the same physician on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.”

I have heard arguments for using the -25 modifier in both cases: for services provided by only one physician and also for multiple doctors within the same practice. And I understand how important it is to follow literal definitions.

However, the reimbursement process is a collision of three very different worlds. First, there’s the clinical world in which the practitioner is trying to offer the best care possible and document as such.

Second, there’s the coding world in which that documentation is filtered through an imperfect language of codes to represent what was done. Third, there’s the billing world in which each government and commercial payer and state can mandate various rules for how clinicians get paid.

Because both doctors in that original scenario are part of the same practice and use the same tax ID number, I’m fine sticking with my original answer. I’ve used the -25 modifier in just this situation for multiple physicians within a group, and I’ve never had any problems with those claims. You do need to use the modifier, though, to show the payer that there is a reason both services should be paid.

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How to Bill a Consultation at the Hospital (Inpatient)

Inpatient billing can be confusing.

The first aspect to understand is that it is not based on the status of the patient. New or established status does not apply to inpatient billing codes, as they are used for an initial doctor visit, whether the practitioner has an established relationship with the patient.

Second, the old initial consultation codes (99251-99255) are no longer recognized by Medicare Part B, although many non-Medicare providers still use them if the payer doesn’t follow Medicare guidelines.

Medicare doesn’t accept codes (99251-99255) use (99221-99223) instead

The correct inpatient consultation codes for a first evaluation are 99221-99223. These codes are used for the inpatient History and Physical (H & P), as well as any specialty consultation (limited to one visit from each specialty). In the past, the codes 99221-99223 were used only for the admitting physicians, and the codes 99251-99255 were designated for consulting physicians. The consulting physician codes were dropped from Medicare guidelines due to discrepancies in paid consulting fees and the proper criteria required for those services. The new guidelines require consulting providers also to use 99221-99223.

When determining the appropriate level of the initial admitting code, the same requirements apply as before. All services performed in an office and the resulting hospital admission are reflected (i.e., admission following any evaluation and management (E/M) services received by the patient in an office, emergency room, or nursing facility). If these services are on the same date as admission, they are considered part of the initial hospital care.

The requirements for codes 99221-99223 are more significant than for 99251-99255, and the E/M services levels must be met, taking into account the length of the visit and depth of decision making.

No matter whether billing for Medicare or a non-Medicare provider, only one inpatient initial code can be billed for each specialty. Additional submissions will be denied. Subsequent hospital visits should be coded using 99231-99233 (not discussed explicitly in this writing).

Billing CPT Codes for Inpatient Initial Hospital Visits to Medicare:

99221:

30 minutes bedside
First inpatient encounter narrative
Comprehensive H & P
Low-level medical decision-making

99222:

50 minutes bedside
Moderate-level medical decision-making

99223:

70 minutes bedside
High-level medical decision-making

Billing CPT Codes for Consulting Inpatient Initial Hospital Visits Outside of Medicare Guidelines

99251:

Typically minor conditions
20 minutes bedside
Problem-focused medical history
Problem-focused exam
Straightforward medical decision-making

99252:

Low-severity conditions
40 minutes bedside
Expanded problem-focused medical history
Expanded problem-focused exam

99253:

Moderate-severity conditions
55 minutes bedside
Detailed medical history
Detailed exam
Low-complexity medical decision-making

99254:

Moderate-to-high-severity conditions
80 minutes bedside
Comprehensive history
Comprehensive exam
Moderate-complexity medical decision-making

99255:

110 minutes bedside
High-complexity medical decision-making

The required documentation for a consulting visit includes:

A request (verbal or written) from the referring physician
The specific opinion or recommendations of the consulting physician
A written report of each service performed or ordered on the advice of the consulting physician
The medical expertise requested is beyond the specialty of the requesting physician

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April 27, 2024

Consultation Codes

First, CMS stopped recognizing consult codes in 2010. Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) were still active CPT ® codes, and depending on where you are in the country, are recognized by a payer two, or many payers.

In 2023, codes 99241 and 99251 are deleted. These two low level consult codes were rarely used. There are four levels of office/outpatient consults and hospital consults. These correspond to the four levels of medical decision making.
CPT has removed the coding tip –and all language– regarding transfer of care.
CMS is not planning on changing its policy on consultations.

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.”

In this article about consultation codes update:

Category of code for payers that don’t recognize consult codes
Definition of a consultation–updated with 2023 CPT guidance
2023 documentation changes

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Including updates on CPT ® and CMS coding changes for 2024

Category of code for Medicare and other payers that don’t recognize consult codes

When CMS stopped paying for consults, it said it still recognized the concept of consults, but paid for them using different categories of codes. 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.

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.

For patients seen in the emergency department and sent home, use ED codes (99282—99285).

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.

Definition of a consultation

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 requirements for a consultation have not changed.

There is a request from another healthcare professional or other appropriate source
An opinion is provided, and
A report is returned.

From 2023 CPT : “A consultation is a type of evaluation and management service provided at the request of another physician, other qualified health care professional, or appropriate source to recommend care for a specific condition or problem. A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.”

CPT goes on to say that if the consultation is initiated by a patient or family member or other appropriate source, do not use consult codes. The list of professionals who are “other appropriate sources” according to CPT includes non-clinical social workers, educators, lawyers or insurance companies. However, if your payer still recognizes consults, they will likely require the NPI of a requesting clinician. You likely will not get paid for a consult requested by one of these professionals.

A report is required. “The consultant’s opinion and any other services that were ordered or performed must also be communicated by written report to the requesting physician, other qualified health care professional, or other appropriate source.”

CPT does not say how the written report is returned: mail, fax, electronic communication.

When you look in your book, notice that CPT has entirely removed the concept of transfer of care . There is no longer a notation that says you cannot bill a consult for a transfer of care.

Consults in 2023 use medical decision making or time

The AMA has extended the framework for office and outpatient services to consults in 2023. Use either medical decision making or the practitioner’s total time on the date of the visit to select the level of service.

Consulting physician services for hospitalized Medicare patients

What should a consulting physician bill when seeing a hospitalized Medicare patient? An initial hospital service or a subsequent hospital visit?

Medicare stopped recognizing and paying consult codes, but consults are still requested and provided to inpatients every day. The question is, how should they be billed?

If the documentation supports an initial hospital service, use codes 99221-99223, initial hospital care codes. According to CPT ® , these codes are used for new or established patients. While we think of them and even talk about them as “admission” codes, CPT ® doesn’t use that word.

If the documentation doesn’t have a detailed history and detailed exam, then bill a subsequent hospital visit, rather than the initial hospital care services. But, the correct category of code is initial hospital care. The citation from the Medicare Claims Processing Manual is at the end of this Q&A.

Many commercial insurance companies still recognize consults. Neglecting to bill consults when the carrier pays them results in lost revenue.

Citation from CMS | Inpatient Hospital Services

The CMS Claims Processing Manual, Chapter 12, §30.6.9 F

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 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. In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. Subsequent hospital care codes 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. A/B MACs (B) shall not find fault 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.

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Last revised March 15, 2024 - Betsy Nicoletti Tags: office and other E/M

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

A step-by-step approach that saves time coding E/M office visits can now be tailored to hospital and nursing home E/M visits as well.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2023;30(1):8-12

Author disclosure: no relevant financial relationships.

Following the major revisions to coding evaluation and management (E/M) office visits in 2021, 1 a similar revamp has been made for coding E/M visits in other settings. Effective Jan. 1, 2023, the history and physical examination requirements have been eliminated for coding hospital and nursing home visits. 2 As with office visits, hospital and nursing home coding is now based solely on medical decision making (MDM) or total time (except for emergency department visits, which must be coded based on MDM, and hospital discharge visits, which must be coded based on time). This further streamlines E/M coding, creating one unified set of rules for office, nursing home, and hospital visits.

Hospital and nursing home E/M visits are divided into three groups: initial services (i.e., admissions), subsequent services, and discharge services. According to the American Medical Association (AMA), initial visits are “when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.” 2 After the patient has received care from that group once, all other visits are subsequent until the discharge service. When the patient transitions from inpatient to observation, or vice versa, that does not begin a new stay eligible for an initial services visit.

CPT codes 99234-99236 are for patients admitted to the hospital and discharged on the same date. For patients with multi-day stays, use 99221-99223 for initial services, 99231-99233 for subsequent visits, and 99238-99239 for discharge services.

Initial nursing home visits are coded with 99304-99306. CPT is deleting the code for nursing home annual exams (99318), which will instead be coded as subsequent nursing home visits (99307-99310).

Two sets of observation care codes (99217-99220 and 99224-99226) should no longer be used as of Jan. 1. Observation services have instead been merged into the corresponding initial service, subsequent service, and discharge codes.

These changes open the door to a simpler, quicker coding process. Many of the principles that already apply to E/M office visit coding now apply to hospital and nursing home E/M coding, but there are some differences in the details. This short guide can help physicians navigate the changes.

Coding for evaluation and management (E/M) visits in hospitals and nursing homes is now much like coding E/M office visits.

This unified set of coding rules allows physicians to quickly code nearly all visits using a template that starts with total time.

There are a few key differences to be aware of, such as total time spent past midnight on the date of service can be counted for hospital E/M visits, but not for office E/M visits.

MEDICAL DECISION MAKING

Determining the level of MDM for hospital and nursing home visits is now much like doing so for office visits. 3 The four MDM levels are straightforward, low, moderate, and high. They are determined by three factors: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the patient's risk of complications, morbidity, or mortality.

If you feel confident coding office visits based on MDM, you can use that knowledge to code hospital and nursing home visits based on MDM as follows:

A level 1 initial or subsequent hospital visit requires the same MDM components as a level 3 office visit,

A level 2 initial or subsequent hospital visit requires the same MDM components as a level 4 office visit,

A level 3 initial or subsequent hospital visit requires the same MDM components as a level 5 office visit.

Several medical decisions that are more common in hospitals than office settings carry enough risk that, when paired with high-level problems, they call for the top visit level. These include the decision to escalate hospital care (e.g., transfer to the intensive care unit), the decision to deescalate care or discuss do-not-resuscitate orders due to poor prognosis, the decision to use IV narcotics or other drugs that require intensive monitoring, and decisions regarding emergency surgery for patients with or without risk factors or non-emergency surgery for patients with risk factors.

There are new time thresholds for each level of service for initial hospital visits, subsequent hospital visits, and nursing home visits to use when you are coding by total time. Instead of offering a time range like office visits (e.g., a 99214 office visit requires 30–39 minutes), nursing home and hospital care visits require that you meet or exceed specific times (e.g., a 99232 subsequent hospital visit requires 35 or more minutes).

When coding initial hospital visits by total time, you can count all the time you spend caring for the patient on admission even if some of it extends after midnight on the calendar day of the admission. According to the AMA, “a continuous service that spans the transition of two calendar dates is a single service and is reported on one calendar date. If the service is continuous before and through midnight, all the time may be applied to the reported date of service.” 3 This differs from office visits, for which you may count only the time on the date of the visit. Otherwise, the definition of total time for hospital and nursing home E/M visits is similar to that of office visits. It includes the time you personally spend on E/M for that patient before, during, and after the face-to-face services. It does not include staff time, time spent on separately reportable procedures, travel time, or teaching time.

A SIMPLER WAY TO CODE

Like the 2021 changes to office visit E/M coding, the 2023 changes should make coding hospital and nursing home E/M visits simpler and quicker.

The universal coding template suggests coding by time first if that will appropriately credit you for the work you did. It's the most straightforward and easy method. But if you believe MDM will credit you for a higher level of work, then step 2 is to determine what level of problems (low, moderate, or high) you addressed and whether you managed (prescribed, adjusted, or decided to keep the same) a prescription medication. Answering those two questions allows you to code most visits quickly using MDM. For the few visits that remain, you will need to proceed to steps 3 or 4, which may require you to tally data points and are therefore more time-consuming.

The template was adapted from a prior FPM article on office E/M coding 4 by adding nursing home and hospital visit times and relabeling office-visit level 3, 4, and 5 problems as low-, moderate-, and high-level problems.

UNIVERSAL CODING TEMPLATE

Step 3: MDM with simple data

Moderate-level problem PLUS one of the following:

Interpret one study (e.g., “I personally looked at the x-ray, and it shows …”),
Discuss patient management or a study with an external physician (one who is not in the same group practice as you or is in a different specialty or subspecialty),
Modify workup or treatment because of social determinants of health.

EQUALS moderate-level visit, even without medication management (see codes in Step 2).

Step 4: MDM counting data points

Moderate-level problem PLUS at least three points from data counting (below),

EQUALS moderate-level visit (see codes in Step 2).

High-level problem PLUS at least two of these three:

Interpret one study (e.g., "I personally looked at the x-ray, and it shows..."),
Discuss patient management or a study with an external physician,
At least three points from data counting (below),

EQUALS high-level visit (see codes in Step 2).

Data counting:

Review/order unique test/study: 1 point for each,
Review external notes: 1 point for each unique source,
Assessment requiring use of an independent historian (family member or other person who can provide a reliable history for a patient who is unable to): 1 point max.

Documentation to support your coding should also be easier going forward. While documenting a medically appropriate history and physical exam is still certainly important for good patient care, it's no longer required for coding; therefore, you should be able to determine the code level from only a few lines of documentation. The quiz below provides some examples to pair with the coding template for practice.

Hopefully, using this step-by-step approach to the 2023 E/M coding changes will allow you to code many types of visits more quickly and accurately so you can spend more time with your patients and less time on the computer.

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

CPT evaluation and management (E/M) code and guideline changes. American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Table 2 - CPT E/M office revisions level of medical decision making (MDM). American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Millette KW. A step-by-step time-saving approach to coding office visits. Fam Pract Manag . 2021;28(4):21-26.

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More in FPM

Coding Corner: Inpatient Consultations Via Telemedicine

With Sameer Sharma, MD, MBA, Society of Gynecologic Oncology (SGO) member and Director, Gynecologic Oncology at Northwest Cancer Center in Dyer, IN, and an Assistant Professor at Rush University in Chicago, IL.

Sameer Sharma, MD, MBA

Inpatient consultations via telemedicine can be used to substitute for a face-to-face encounter for initial and follow-up inpatient consultations, as well as for specialist consultations to discuss advice and recommendations physician-to-physician. These guidelines are constantly evolving during the COVID-19 public health emergency.

Initial Inpatient Consultations:

Medicare pays for reasonable and medically necessary inpatient telehealth consultation services furnished to beneficiaries in hospitals when your facility meets the following criteria for the use of a consultation code:

The physician of record or the attending physician requests the initial inpatient telehealth consultation for their patients located in the hospital or emergency room and documents this in the patient’s medical record.
A consultant or qualified health provider (QHP) needs to document the request for the inpatient telehealth consultation from an appropriate source and the need for an inpatient telehealth. The consultant then places this information in the patient’s medical record and lists the requesting physician.
The visit can be performed with audio/video two-way communication; many states will also allow audio alone two-way communication.
The consultant needs to prepare a written report of his/her findings and recommendations. Patient and QHP location should be listed in the record.
Typically, these services are reported as telehealth services when the individual QHP is not at the same location as the beneficiary but there are no apparent limitations to the QHP location.
The Medicare reimbursement for the consultation would include all related services furnished before, during, and after communicating with the patient via telehealth.
Teaching Physicians: Under the so-called primary care exception at section, a teaching physician may meet the requirement to review a visit furnished by a resident remotely using audio/video real time communications technology.

These services include, but are not limited to:

Reviewing the patient’s diagnostic imaging and lab work
Communicating with other physicians or family
Documenting the visit in the patient’s chart
Discussing the results of the telemedicine consultation
Developing further care plans

The following codes should be used for an initial inpatient telemedicine consultation:

wRVU: work Relative Value Units

Follow-up Inpatient Consultations:

Telemedicine can be used to manage follow-up inpatient telehealth consultations furnished to patients in hospitals. These encounters can only occur after the patient’s initial consultation.

The visit can be performed with audio/video two-way communication; many states will also allow audio alone two-way.
The initial inpatient consultation can be provided as either as an in-person encounter or a telemedicine visit.
A subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days as per previous guidelines.

Follow-up inpatient telehealth consultations could include, but are not limited to, the following services:

Monitoring progress
Suggesting management modifications
Recommending a new plan of care based on changes in the patient’s status
Coordinating care with other providers or agencies
Communicating with other professionals
Reviewing patient data
Discussing the case with the patient’s family
Completing medical records or other documentation
Communicating the results of the consultation

The following codes should be used for a follow-up inpatient telemedicine consultation:

Related Resources

IMAGES

2023 Evaluation and Management Guideline Changes for Hospitalists
Coding Inpatient and Observation Visits in 2023
CPT 2022: Care Management & Other CPT Code Updates
The 2023 Hospital and Nursing Home E/M Visit Coding Changes
The CPT code changes that hospitalists need to know
What Is A Medicare Cpt Billing Code?

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COMMENTS

Coding Inpatient and Observation Visits in 2023
Effective Jan. 1, 2023, hospital observation codes 99217-99220 and 99224-99226 are deleted. These services are merged into the existing hospital inpatient services codes 99221-99223, 99231-99233, and 99238-99239, and the subsection is renamed Inpatient Hospital or Observation Care. As in the Office or Other Outpatient Services subsection, the ...
CPT code 99221, 99223, 99222 and 99233
When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report an Initial Hospital Care from CPT code range 99221 - 99223 and a Hospital Discharge Day Management service, CPT code 99238 or 99239.
PDF Coding for hospital admission, consultations, and emergency ...
billed as subsequent hospital care visits (99231-99233). The coding depends on the admission status of the patient when seen and whether the patient is classified as Medicare or non-Medicare. For Medicare patients, inpatient consultations are reported with the initial hospital visit codes (99221-99223). Do not append modifier Ai, which is only
Coding Hospital Admissions From Other Sites of Service
Also, section 15505.1.F states, "Advise physicians to use the initial hospital care codes (codes 99221-99223) to report the first hospital inpatient encounter with the patient when he or she ...
PDF MLN906764 Evaluation and Management Services Guide 2023-08
Split (or Shared) E/M Services. CPT Codes 99202-99205, 99212-99215, 99221-99223, 99231-99239, 99281-99285, & 99291-99292. A split (or shared) service is an E/M visit where both a physician and NPP in the same group each personally perform part of a visit that each 1 could otherwise bill if provided by only 1 of them.
PDF 2023 Evaluation and Management Changes: Inpatient, Observation, and
services beginning in January 2023 which combined observation and inpatient services into one code set. Observation CPT® codes 99217, 99218-99220, 99224-99226 were deleted as of January 1, 2023. 2022 2023 Observation Services Initial: 99218-99220 Subsequent: 99224-99226 Discharge: 99217 Hospital Inpatient and Observation Care Services
Understanding CPT Code 99222 For Hospital Visits
CPT Code 99222 is used for the initial hospital inpatient or observation care. It requires a medically appropriate history and/or examination. A moderate level of medical decision making (MDM) needs to be documented. For time-based code selection, a minimum of 55 minutes must be spent. Medicare covers CPT Code 99222.
Jurisdiction M Part B
Published 01/25/2021. 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. First, CMS reminds providers that CPT code 99221 may be reported for an E ...
PDF Hospital Coding… Making the Rounds
Hospital Observation Services. 99234-99236. Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours on same calendar day. Documentation identifying the billing provider was present and personally performed the services.
PDF Observation Services
Initial Observation Care (CPT code range 99218-99220) When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 - 99220, shall be reported by the physician. When a patient is admitted for observation care and then is discharged on a different calendar date ...
Coding for consults and readmissions
Initial hospital visits (99221-99223) Subsequent hospital visits (99231-99233) Discharge services (99238-99239) Critical care services (99291-99292) Inpatient consultations (for non-Medicare patients) (99251-99255) Working with residents Say a patient is admitted at 10 p.m., when the resident team sees the patient, writes an H&P and does all ...
PDF CPT CODE 99223
of a face-to-face visit. Even if a complete note is generated, only the necessary services for the condition of the patient at the time of the visit can be considered in determining the level/medical necessity of any service. Initial Hospital Care (New/Established Patients) Components Required: 2 of 3 99221 99222 99223 History & Exam Detailed •
PDF CMS Guidance Document
30.6.9 - Payment for Inpatient Hospital Visits (Codes 99221 - 99239) (Rev.) A. Hospital Visit and Critical Care on Same Day When a hospital inpatient (or emergency department, or office/outpatient) evaluation and management service (E/M) is furnished on a calendar date at which time the patient does
PDF CPT® Evaluation and Management (E/M) Code and Guideline Changes
and/or descriptors. For this reason, code numbers and/or descriptor language in the CPT code set may differ at the time of ... • E/M Introductory Guidelines related to Hospital Inpatient and Observation Care Services codes 99221-99223, 99231-99239, Consultations codes 99242- ... such as office visits, hospital inpatient or ...
How to Bill a Consultation at the Hospital (Inpatient)
Additional submissions will be denied. Subsequent hospital visits should be coded using 99231-99233 (not discussed explicitly in this writing). Billing CPT Codes for Inpatient Initial Hospital Visits to Medicare: 99221: 99222: 99223: Billing CPT Codes for Consulting Inpatient Initial Hospital Visits Outside of Medicare Guidelines. 99251: 99252:
Consultation Codes Update
April 26, 2024. Consultation Codes. First, CMS stopped recognizing consult codes in 2010. Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) were still active CPT ® codes, and depending on where you are in the country, are recognized by a payer two, or many payers. In 2023, codes 99241 and 99251 are deleted.
A Step-by-Step Time-Saving Approach to Coding Office Visits
Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to ...
The 2023 Hospital and Nursing Home E/M Visit Coding Changes
Initial nursing home visits are coded with 99304-99306. CPT is deleting the code for nursing home annual exams (99318), which will instead be coded as subsequent nursing home visits (99307-99310 ...
Coding Corner: Inpatient Consultations Via Telemedicine
Telemedicine can be used to manage follow-up inpatient telehealth consultations furnished to patients in hospitals. These encounters can only occur after the patient's initial consultation. The visit can be performed with audio/video two-way communication; many states will also allow audio alone two-way. The initial inpatient consultation can ...