# Inpatient H&P when HPI doesn't meet criteria



## oceangirl752002 (May 15, 2020)

If anyone could help to clarify I'd appreciate it...

My provider admitted a patient to the hospital but the documentation in the H&P does not support the level she wants to charge. HX = EPF, EXAM = comprehensive & MDM = HIGH. Hospital Inpatient admissions have only detailed or comprehensive for history level. If there are not enough bullets in the HPI to qualify for an extended HPI, what do you bill? 

Thanks.


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## Orthocoderpgu (May 15, 2020)

If your physician admitted the patient, why are they not billing the admit code?


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## oceangirl752002 (May 15, 2020)

Orthocoderpgu said:


> If your physician admitted the patient, why are they not billing the admit code?


They are, but the history level is only expanded problem focus, and hospital inpnt 99221 - 99223 only support a detailed or comprehensive history.


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## SharonCollachi (May 15, 2020)

*The Hospitalist* has this to say, from when Medicare eliminated consults:

*Incomplete Documentation*

Initial hospital-care services (*99221*-*99223*) require the physician to obtain, perform, and document the necessary elements of history, physical exam, and medical decision-making in support of the code reported on the claim. There are occasions when the physician’s documentation does not support the lowest code (i.e., *99221*). A reasonable approach is to report the service with an unlisted E&M code (*99499*). “Unlisted” codes do not have a payor-recognized code description or fee. When reporting an unlisted code, the biller must manually enter a charge description (e.g., expanded problem-focused admissions service) and a fee. A payor-prompted request for documentation is likely before payment is made.

Some payors have more specific references to the situation and allow for options. Two options exist for coding services that do not meet the work and/or medical necessity requirements of *99221*-*99223*: report an unlisted E&M service (*99499*); or report a subsequent hospital care code (*99231*-*99233*) that appropriately reflects physician work and medical necessity for the service, and avoids mandatory medical record submission and manual medical review.4

In fact, Medicare Administrator Contractor TrailBlazer Health’s Web site (www.trailblazerhealth.com) offers guidance to physicians who are unsure if subsequent hospital care is an appropriate choice for this dilemma: “TrailBlazer recognizes provider reluctance to miscode initial hospital care as subsequent hospital care. However, doing so is preferable in that it allows Medicare to process and pay the claims much more efficiently. For those concerned about miscoding these services, please understand that TrailBlazer will not find fault with providers who choose this option when records appropriately demonstrate the work and medical necessity of the subsequent code chosen.”4 *TH*

If you want to see what the footnotes say, here is the entire article.


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## AC (May 15, 2020)

Check your payer guidelines. In this situation, my MAC instructs to bill the subsequent hospital code at a level which MDM, history, and exam all meet.  I would code 99232 if moderate or high MDM, 99231 if low.


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## KaylaRieken (May 19, 2020)

If you are not the admitting provider, wouldn't you still code the 99221-99223 if you were called in for a consult? Just without the AI modifier? My providers are urologists and get called in to see inpatients quite often. I was also told if they don't meet the requirements to bill the subsequent codes.


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## SharonCollachi (May 19, 2020)

KaylaRieken said:


> If you are not the admitting provider, wouldn't you still code the 99221-99223 if you were called in for a consult? Just without the AI modifier? My providers are urologists and get called in to see inpatients quite often. I was also told if they don't meet the requirements to bill the subsequent codes.



No.  Go back to the basics.  The CPT book states," [99221-99223] are used to report the first hospital inpatient encounter with the patient by the admitting physician. For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate."

I don't know who told they they don't meet requirements for subsequent codes, but those are the codes you will use.  It doesn't mean subsequent care by that particular physician (your physician), it means hospital care, by day, of the patient by other than the admitting physician.


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## REllington11 (Mar 26, 2021)

Question. If insurance does not cover consults codes in office, am I to assume that consults will be not covered in hospital? Our doctor have been requested to consult patient in hospital but many insurances does not accept consult codes. Do I bill initial 99221 -99223 codes or consults 99251 -99255?


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## csperoni (Mar 26, 2021)

REllington11 said:


> Question. If insurance does not cover consults codes in office, am I to assume that consults will be not covered in hospital? Our doctor have been requested to consult patient in hospital but many insurances does not accept consult codes. Do I bill initial 99221 -99223 codes or consults 99251 -99255?


1) Simply because another physician requested you to see their patient does not necessarily make it a consult.  The inappropriate use of consult codes is what caused Medicare to discontinue their coverage.
2) IF you did in fact meet the 3Rs for consult, then consult codes are appropriate.
3) Most insurance carriers no longer cover consult codes.  If they do not cover them in office, they will not cover them in the hospital setting either. 
4) Medicare guidance is for the consulting physician to use 99221-99223 for the initial hospital visit.  Most commercial carriers follow this same guidance.  Some will only pay 1 physician for initial 99221-99223 and require all other providers to use subsequent 99231-99233 even though it may be your provider's first time seeing the patient.


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## KaylaRieken (Mar 29, 2021)

What are the 3 Rs?


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## SharonCollachi (Mar 29, 2021)

Request Consult, Render the Service, Report back to the requester in writing.


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## KaylaRieken (Mar 29, 2021)

What do you mean by report back to the requester in writing?


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## csperoni (Mar 29, 2021)

Here's a good article explaining consult requirements.  If you don't meet all 3, it's not a consult.  This has been an issue for years and is why Medicare and most other carriers no longer recognize consult codes.  Consult in a non-coding setting simply means another doc asked you to see a patient.  Consult from a coding aspect means something very, very specific.  


			https://www.todayshospitalist.com/the-three-rs-of-consultation-codes-request-render-and-reply/


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## KaylaRieken (Mar 29, 2021)

We do not use the consult codes. Should we follow Medicare rules and use the 99221-99223 for other insurances?


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## SharonCollachi (Mar 29, 2021)

KaylaRieken said:


> What do you mean by report back to the requester in writing?


Send a written report to the doctor that requested the consult.  A consult is a request for an opinion.  A consult is not a transfer of care, in and of itself.  So to fulfill the consult and use consult codes, you must send a report to the person who asked for your opinion.


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## csperoni (Mar 29, 2021)

KaylaRieken said:


> We do not use the consult codes. Should we follow Medicare rules and use the 99221-99223 for other insurances?


That is what we do, specifically because our internal policy is to follow Medicare guidelines.
Every once in a while, I will have an initial visit denied stating it was paid to another physician, which I will appeal with a copy of the Medicare guidelines.  If it is still denied, I will then bill a subsequent.  
You may want to keep a chart of which carriers permit multiple physicians to bill initial.


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## KaylaRieken (Mar 29, 2021)

Yes that is what I have been doing scperoni. If it gets denied, then I will bill the subsequent.


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