# When 3 components are not met for an initial admit



## 1storm (Mar 12, 2008)

I have a question regarding how to bill when 3 components are required to bill but one of the components do not meet. There is an initial hospital care that needs to be coded but there is the physician only did an expanded problem focused exam. 99221 requires at least a detailed exam. Should this be billed with the 52 modifier?


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## codegirl0422 (Mar 12, 2008)

if is not documentated, it was not done. I was instructed my a recent auditor hired to do a external audit, that if you do not have all the elements required then you do not get to bill it. I have always been told modifier 52 is for procedures, modifier 52 is not an E/M modifier.

Did the doctor see the patient in the office and then see the patient in the hospital (same day)? If so, you can combine the two visits and sometimes get a higher level code. 

"When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (eg, hospital emergency department, observation status in a hospital, physician's office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting."-CPT book


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## member7 (Mar 12, 2008)

If all components are not met, I've heard of using 99499 which is an E/M unlisted code for that type of situation.


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## rthames052006 (Mar 13, 2008)

Check with your carrier, or patients health insurance carrier in this case, see how they want you to handle this case, this has happened to our practice in the past and we were told to bill it as subsequent hospital care to the level the note coded out to.  But as I said that was the patients carrier telling us that.

Good luck,

Roxanne Thames, CPC 





1storm said:


> I have a question regarding how to bill when 3 components are required to bill but one of the components do not meet. There is an initial hospital care that needs to be coded but there is the physician only did an expanded problem focused exam. 99221 requires at least a detailed exam. Should this be billed with the 52 modifier?


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## srarick (Mar 13, 2008)

I do not see how you can bill for anything that is deemed to be subsequent when this is actually for an "initial" admit.  

I would say that it is non-billable if all 3 required components are not satisfied.
And then educate your physicians!

Susan Rarick, CPC




rthames052006 said:


> Check with your carrier, or patients health insurance carrier in this case, see how they want you to handle this case, this has happened to our practice in the past and we were told to bill it as subsequent hospital care to the level the note coded out to.  But as I said that was the patients carrier telling us that.
> 
> Good luck,
> 
> Roxanne Thames, CPC


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## codegirl0422 (Mar 13, 2008)

I had heard this also in a conference I attended, but when I was audited recently and I asked her about it, I was told that it is non billable and the phyisician probably needs to educated on this. Her explanation was the visit is not subsquent so you can bill as a subsq code. I don't know if this helps or not. If it is Medicare, Medicaid, Tricare, or other gov carrier, I would definitely not bill as subsq. If ever audited, this may be a problem.



rthames052006 said:


> Check with your carrier, or patients health insurance carrier in this case, see how they want you to handle this case, this has happened to our practice in the past and we were told to bill it as subsequent hospital care to the level the note coded out to.  But as I said that was the patients carrier telling us that.
> 
> Good luck,
> 
> Roxanne Thames, CPC


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## Cottrell (Mar 14, 2008)

*99499*

I keep seeing this issue come up. According to Medicare 99499 is NOT to be used to fill the gap between two level of E&M service within a category or subcategory.
Medicare B news Issue 237 May 29 2007 states
" CPT code 99499 NEVER to be used to interpolate between two levels of E/M service within a category or subcategory. Rather the next lower code for which ALL criteria are met is the appropriate choice"
When talking about "admiting a patient to inpatient status from observation subsequent to the date of admission to observation, the physician must bill an intial hospital visit for the services provided on that date"
#2 If criteria for even a 99221 "inpatient admission" are not met, but a service was necessary, and all of the required componenets performed and appropriately documented meet criteria for a "subsequent Visit" (99231-99233) then that level of service is appropriate for billing and payment (even though the service is chronilogically an "admission")

Consults are also billed as the level of service the meet.

This is in the Medicare Claims Processing Manual, IOM 100-04 Chapter 12-Physician/Practioner Billing, 30.6.1.
Hope this helps clear up some confusion.

Wendy


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## rthames052006 (Mar 14, 2008)

[
I don't know if you really read my post, I said that, the particular insurance carrier told us how they wanted it billed in this scenerio... I didn't say to bill it that way to ALL CARRIERS.... and I also stated to CHECK WITH THE PT'S INSURANCE CARRIER FOR CLARIFICATION!!!

Roxanne Thames, CPC





QUOTE=srarick;8696]I do not see how you can bill for anything that is deemed to be subsequent when this is actually for an "initial" admit.  

I would say that it is non-billable if all 3 required components are not satisfied.
And then educate your physicians!

Susan Rarick, CPC[/QUOTE]


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## rthames052006 (Mar 14, 2008)

Thanks Wendy for the information....


Roxanne Thames, CPC






Cottrell said:


> I keep seeing this issue come up. According to Medicare 99499 is NOT to be used to fill the gap between two level of E&M service within a category or subcategory.
> Medicare B news Issue 237 May 29 2007 states
> " CPT code 99499 NEVER to be used to interpolate between two levels of E/M service within a category or subcategory. Rather the next lower code for which ALL criteria are met is the appropriate choice"
> When talking about "admiting a patient to inpatient status from observation subsequent to the date of admission to observation, the physician must bill an intial hospital visit for the services provided on that date"
> ...


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## srarick (Mar 17, 2008)

I didn't mean that to be directed at you as an attack on your knowledge/opinion.  I was just stating that I did not agree with what the carrier advised you to do. (I did read your post)  It was not my intent to upset anybody.


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## rthames052006 (Mar 17, 2008)

I had a really rough week, and I too, may have been to harsh on you for your opinion, so for that I am sorry Sraick.

It's just that so much is still "gray" and with carriers doing things at "their descretion" it makes it hard to know what to do for each "hairy" situation that comes up.

We are all in this together and united we stand. So please accept my apology.

Roxanne Thames, CPC





srarick said:


> I didn't mean that to be directed at you as an attack on your knowledge/opinion.  I was just stating that I did not agree with what the carrier advised you to do. (I did read your post)  It was not my intent to upset anybody.


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