# CPT 99221 for non admitting physician?



## mikesyzf (Apr 6, 2018)

I have seen coders use 99221 for an initial visit (consulting) for an inpt. encounter when requested by the admitting physician. CPT Guidelines for 99221 states .... By the admitting physician..." and that if the physician is not the admitting physician, they are to use 99251-99255 or 99231-99233. My question is: Is it appropriate to use 99221 for a physician who is requested to do a consultation for a patient (that is an inpatient) who is not the admitting physician?


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## mitchellde (Apr 6, 2018)

In the Medicare manual there is a section for alternative consultation billing that was effective as of Jan 1 2010 for Medicare and any commercial carrier that decides to follow Medicare.  In this section you will see where it states  to use the initial visit level codes in place of the consultation levels for all inpatient consultations.  The admitting provider must append the AI modifier to their initial level to distinguish the admitting service from the consultation service.


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## mikesyzf (Apr 9, 2018)

Mitchelled- Thank you for your response. I guess what I am "stuck" on is where the books states :

"The following codes 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"

So if you have a Non Medicare claim, what I am wanting to know is, is CPT 99221-99223 to be used exclusively by the Admitting Physician. 
I have seen clinics use this for the initial encounter even though the physician on the claim was not the admitting physician.
I may be wrong, but I see these codes 99221-99223 to be used by the admitting physician only, but no one that I have spoken to agree with me.


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## mitchellde (Apr 9, 2018)

If they are following Medicare guldelines with respect to consultation services then Medicare guidelines will trump the CPT guidelines.


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## liloe517 (Apr 9, 2018)

https://www.aapc.com/blog/38856-medicare-and-consults-99241-99255/

I found this link and it should answer your question.


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## mikesyzf (Apr 9, 2018)

This is for non Medicare ...........


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## mitchellde (Apr 9, 2018)

Yes , I understand... however many, most commercial Carriers follow Medicare on many of their policies.  The issue of consultation codes is one of these areas.  Shortly after Medicare instituted this policy in 2010 Blue Cross and United also adopted the Medicare policy on discontinuing consultations codes and opting for Medicare’s alternative consultation policy.  To know each individual commercial carriers stance on this, it is advisable to contact each one that you are contracted with to see if they are still allowing consultation codes or if they follow Medicare.
The problem comes in with the vast majority of patients have Medicare as a secondary.  In this instance many have found it best to follow Medicare’s advice and bill to the primary the same way you would bill to Medicare.


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## mikesyzf (Apr 10, 2018)

-Debra, 
I appreciate your input regarding this code and it's and the proper code application for claims affiliated with Medicare, however, for claims that do not follow Medicare, I am still seeking any input as to whether a non admitting physician (non medicare claim) can properly use this code on their claim. Thank you !
-Mike


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## liloe517 (Apr 10, 2018)

My question would be why wouldn't the provider want to use a consult code if they did a consult and the insurance accepts consults?


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## mikesyzf (Apr 10, 2018)

Seems we're getting off topic... Coding question, not a billing question please ......


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## mitchellde (Apr 10, 2018)

Ok sometimes you cannot separate billing and coding issues.  You need to know if the commercial carrier follows Medicare's policy on consultations, If they do not then yes you will code it as a consult code, If they do they you will code it as an initial visit level.  As I said earlier most carriers follow Medicare on this so you would code it as an initial hospital visit for a non Medicare payer.  If you knew the commercial carrier does recognize consultation codes then you would code it as an inpatient consult level.  You will need to be certain that Medicare is not a secondary payer.


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## mikesyzf (Apr 11, 2018)

Ok, this pt. is NOT a Medicare patient. The pt.'s Ins DOS NOT follow Medicare guidelines. What I am asking is :does anyone have experience dealing with this code and the wording "By the admitting physician" since that is clearly stated in the book and that the book addresses for physicians other than the admitting. Is it appropriate to use 99221 for a physician who is requested to do a consultation for a patient (that is an inpatient) who is not the admitting physician?


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## mitchellde (Apr 11, 2018)

If the payer is not following medicare and the provider performs a consultation in the inpatient setting then you will not code with the initial inpatient codes, you will use the appropriate consultation services.  I have stated this in each response I am not sure where the question is at this point.


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## mikesyzf (Apr 11, 2018)

Pt. is seen in ER. Physician #1 ADMITS the pt.  Next day (still inpt.) Physician #2 is consulted on the pt.'s condition. The CPT books states for CPT code 99221-223: 

" The following codes are used to report the first hospital 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 visit hospital care codes (99231-99233) as appropriate"

The issue is, Physician #2 wants to use the 99221 even though he/she IS NOT the admitting physician. Agreed the physician should use a consultation code IF the Ins allows for it. I don't think the consulting physician (#2) should use 99221 but our lead states it ok. Anyone with any experience with this Code?


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## mitchellde (Apr 11, 2018)

As long as the patient does not have Medicare as a secondary and you know the payer allows for consults, it would be incorrect to use an initial visit level for the consultation.


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