# Initial Hospital Care vs Subsequent Hospital



## jlb102780

Hello to all,

I am going back and forth with some of my doctors (cardiologists). They were given what I consider to be incorrect information. They seem to think that ALL (Consult) calls coming from the hospital can be bill out as a new initial hosp care visits regardless of the pts history with us and why we were called.

Example: Pt known to our practice for a-fib, goes to the ED in renal failure. Pt gets admitted as inpt to hosp. We get called due to the history of the pt having a-fib. Wouldn't this be considered a "transfer of care", and billed as a subsequent visit, not a new initial visit?

Example: Pt with known CAD has CABG done by cardiovascular surgeon, once CABG is performed the surgeon then transfers the pts care to his regular cardiologist to follow during the pts hosp stay. Again, isn't this a "transfer of care", not a new initial visit?

Example: Pt with known CAD comes into ED with rapid heart rate, we get called for a consult due to the rapid heart rate. Pt is admitted by hospitalist as inpt. Pt found to have new onset of A-FIB. This WOULD be considered a new initial hosp visit. 

Any input would be greatly appreciated. I'm pretty sure I understand the guidelines, I'm just having trouble getting my docs to believe me.


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## donna_vig

1)  Transfer of care would mean that the Cardiologist is assuming primary care of the patient.  I'm assuming that the hospitalists is still managing the patient renal failure and still the attending.  The cardiologist would've been called in for a consultation due to the patient's known cardiac condition.  There is no new vs established in the facility setting so this would be considered a consult.

2)  I'm concerned that the cardiothoracic surgeon would transfer care within the same hospital stay of a major procedure.  Most cardiothoracic surgeons continue the 90 day global follow up and refers the patient to the cardiologist for long term care.

It doesn't matter if the patient is established with the specialist.  If it were a cardiac condition then the ED doc would order the cardiology consult.  If the cardiologist admits the patient, the consult then become part of the H&P because here could only be one E&M submitted per day.  The main thing would be in the documentation.  If the attending orders a consult, then it's a consult.  If the attending orders the transfer of care, then it's a transfer of care. 

CMS.gov has great information for how to code E&M.  In the manuals, 100-04, chapter 12, section 30.6 is the E&M guidance.  You'll find direction on consultations there too.  I hope this helps.


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## mitchellde

A transfer of care for a specific diagnosis or course of treatment does not constitute a transfer of attending.  If a provider admits a patient and calls the patient's cardiologist to inform them their patient is admitted and needs to be seen for their cardiology issues, this is not a consult and will be billed using the subsequent codes.   It is not a consult to be requested to see a patient for issues you are already treating.  Having worked inpatient, a patient can have numerous physicians that come each day all for their individual reason, and not a single one is a consult, yet the patient has one primary attending physician.  
So no consult to go and see your patient that has been admitted by another provider.
You are correct it is a transfer of care for the surgeon to transfer care back to the cardiologist and is not a consult.  Yest the surgeon will continue to see his patient post op but the attending privelges goes to the cardiologist and he now gets to determine the day of discharge from ICU and discharge from the hospital.


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## LLovett

*I'm going to have to side with the doctors on this one....*

Per CMS once the consult codes went away "In the inpatient hospital setting and nursing facility setting, any physicians and qualified NPPs who perform an initial evaluation may bill an initial hospital care visit code (CPT code 99221 – 99223)".

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM6740.pdf

So no matter the reason, the first time a provider sees the patient on the inpatient side, they can bill an initial care code if the documentation supports it. If it does not, then they have to down code to the subsequent care code supported by documentation. If they don't have enough for subsequent care they have to go unlisted.

http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0706_emfacility.shtml

Question 2: Please confirm that only the "admitting" physician can use an initial hospital care code. How do you define "admitting" versus "attending?" Dr. A admits Mr. Smith to the hospital. Dr. A makes a brief visit and writes orders for Mr. Smith's medications. The next day, Dr. B, Mr. Smith's attending physician sees Mr. Smith and meets the criteria for a 99222. What service should Dr. A and Dr. B submit to Medicare?
Answer: For services January 1, 2010, and after CMS discontinued the use of consultation codes for Medicare services and as part of this change, more than one physician may bill an initial inpatient visit. Physicians other than the "admitting", "attending" or the "principle physician of record" may bill an initial visit when the medical documentation supports the level of service and a member of the same group with the same specialty did not previously provide an initial inpatient service. The principle physician of record appends modifier AI to their initial inpatient service. 

If the documentation for the initial visit does not support one of the initial inpatient procedure codes, CMS has instructed contractors to not find fault with the physician billing a subsequent care procedure instead. 

For services prior to January 1, 2010, according to the CMS IOM Publication 100-04, Chapter 12, Section 30.6.9.1.G, only the admitting physician of record may bill the initial hospital visit procedure codes. Only one physician may be the admitting physician. CMS has not provided a definition of admitting and/or attending physician. Medicare defines the principle physician of record as the physician responsible for the patient's care will inpatient. 



Laura, CPC, CPMA, CEMC


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