# Transfer of Care - conservative treatment



## nrichard (Aug 3, 2011)

I work for a multispecialty group and our physicians get called into the hospital to assume care of the patient. I know this isn't a consult since they are usually performing surgery on the patient. This usually occurs on the same day or after a few days of conservative treatment. 
    My thought on this was to code these as Initial Hospital Care, but I see that this is described as being for the admitting physician. So it appears that this would be correct if our physician is admitting the patient from the ED or Observation status. My question is this; is it appropriate to bill the Subsequent Hospital codes when our physicians did not admit the patient (to the hospital)? Or due to the fact this is the initial visit/ admission to our practice would it be appropriate to still bill Initial Hospital Care? It does not appear to be clear cut that by definition that the term; admit, applies to the hospital or to a practice.
Thanks,
Nichole CPC


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## MnTwins29 (Aug 3, 2011)

*Initial Hospital Visits are not just for the admitting MD anymore*

If your physician sees the patient in the hospital, an intial hospital visit can be used.  The admitting physician will use the modifier -AI to indicate he or she admitted the patient.   Also, after the surgery, as long as the visit is not part of the surgical package as follow-up care, subsequent hospital visit codes would be appropriate.


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## Pam Brooks (Aug 3, 2011)

I don't necessarily agree with all of this.

CPT describes the codes 99221-99223 as being used to report the first hospital inpatient encounter by the admitting physician. CPT goes on to explain that 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). 

The only time you'd use these initial hospital care codes for physicians other than the admitting is when the patient's payer (i.e. Medicare) does not accept the consult code, and Medicare instructs us to use the 99221-99223 as a substitute. It's correct that you use the -AI modifier to differentiate between the attending's visits and the consultant's. Not all payers follow this exception, so to use these codes for the 'first visit' in the inpatient setting by any other provider wouldn't be appropriate, particularly if a consult hasn't been called.  Remember, transfer of care is _not_ a consultation.  

Bottom line regarding transfer of care:  If the admitting provider is handing off the case, and not asking for an opinion, I'd bill from the 99231-99233 range. If the patient is not currently admitted with inpatient status, (say, in the ED), and your provider comes into the facilty and admits the patient under his care, then the patient status has changed, and your provider is the admitting provider...you'd bill 99221-99223. 

These kinds of scenarios are what keep us employed!


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## MnTwins29 (Aug 3, 2011)

*Two thoughts*

One is on Pam's post:   on the first paragraph, she cites the CPT instructions for use of the codes.  No argument or disagreement - that is what they say.   In her second paragraph, she then goes on to use payer guidelines (Medicare, then others) that should guide us whether to use initial or subsequent care services.   And THAT is what prompted me to reply - I do disagree with this, but not with what Pam wrote.  What drives me crazy is what are we supposed to do - follow CPT guidelines or payor guidelines when they conflict, as they do here?   I can speak for our practice that since the only payor we contract with that does accept consultation codes is our locals, it can be simpler and we follow the Medicare guidelines for these situations.  

Second thought - upon re-reading the original post, I am wondering if there should even BE an inital visit E/M service recorded.   If the physician is called in to perform surgery if an emergency or conservative treatment failed, is a complete E/M service performed or is a quick assessment of the patient done to be sure the surgery is safe?  Lacking specific documentation, in the second scenario I posed here, that sounds like it would be part of the surgical package and no separate E/M service would be performed.

Just my $0.02


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## nrichard (Aug 3, 2011)

*All of you bring up good points.*

I did forget to add to my original comment that most of these are MCR patients, also there is a full E&M performed due to the nature of our sub-specialties in this group it is not always known if our physician is brought into the picture (to take overcare, offer an opionion, or to perform surgery) These codes are only being billed when the E&M happens more than 24 hours in advance.


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## Pam Brooks (Aug 4, 2011)

Good points, Mntwins29.  In regards to your dilemma..CPT vs. Payer...you have signed a contract with the payer to bill as they ask, so the payer trumps CPT in those cases.

With a surgery that has a 90 day global, you can bill an initial E&M (check your CCI edits for further information).  If the procedure has a 0 or 10 day global, it's bundled in.  

My next job is going to be delivering flowers for a florist.....smells nice, everyone's always glad to see you, and the flowers don't talk back.


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## MnTwins29 (Aug 4, 2011)

Pam, call me if you need a co-pilot for that next job - sounds like a good plan!


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