# Initial Hospital Care - bill the initial code



## Kocur1 (Jul 2, 2013)

Does anyone adds modifier -52 to Initial Hospital code when the documentation does not meet the criteria to bill the initial code? We were instructed to do by our Compliance person for commercial patients. I was wondering if someone bills this way. We bill subsequent code for Medicare patient for the same situtation.
Thank you!
Iz


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## mitchellde (Jul 2, 2013)

modifier 52 cannot be appended to E&M codes ever. See CR1776.  If your documentation does not allow for a selection of an initial code you bill the subsequent or unlisted E&M .
"In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate. CPT modifier -52 (reduced services) mustnot be used with an evaluation and management service."


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## Kocur1 (Jul 2, 2013)

Thank you! This is what I try to argue with our Compliance for last month without any results, plus they have no supprting documentation.
I can't locate CR1776. Can you provide me with a link to that information?
Thanks.


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## mitchellde (Jul 2, 2013)

it is a little obscure .. it is from October 2002, Let me see if I can obtain it and send you the link.


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## mitchellde (Jul 2, 2013)

here is a link that should get you to it:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r1776b3.pdf


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## RebeccaWoodward* (Jul 2, 2013)

Kocur1 said:


> Does anyone adds modifier -52 to Initial Hospital code when the documentation does not meet the criteria to bill the initial code? We were instructed to do by our Compliance person for commercial patients. I was wondering if someone bills this way. We bill subsequent code for Medicare patient for the same situtation.
> Thank you!
> Iz



In addition to Debra's link...

Can I submit a subsequent hospital visit if my documentation does not support one of the three levels of an initial hospital visit?

Answer
*Consultant *
Yes. If the minimal documentation requirements for the initial hospital visit (CPT codes 99221-99223) have not been met, the appropriate subsequent hospital visit (CPT codes 99231-99233) may be submitted. 

*Principal Physician of Record (Admitting Physician)*

_No. If the minimal documentation requirements are not met the principal physician of record (admitting physician) may submit the unlisted E/M CPT code 99499. Do not submit a subsequent hospital visit._

Note: Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment.

As you can see, there are different reporting guidelines for the consulting provider versus the initial inpatient visit.

Palmetto GBA:

http://www.palmettogba.com/palmetto...Asked Questions~EM~8EEM5Z2688?open&navmenu=||

Q. How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?

A. There is not an exact match of the code descriptors of the low level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.” 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/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252*, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.


http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE1010.pdf


Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.

Page 61


http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf


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## Kocur1 (Jul 2, 2013)

Thank you so much! This is very helpful!
Izabela


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