# Initial Consult or Subsequent Hospital Visit??



## cindyt (Jul 30, 2013)

I have a patient who received anesthesia for a spinal fusion on 7/10/13.  On 7/11/13 the same group of anesthesiologists provided a follow-up pain visit.  There is no mention of the requesting physician in the medical documentation of the 7/11/13 visit.  The patient does not have Medicare.  Would this be coded as an initial consult (99251-99255) or a subsequent hospital visit (99231-99233)?  Thanks


----------



## dwaldman (Jul 30, 2013)

How did the Anes. doctor document the consult/encounter. Was it dictated? Was evident they were aware who requested the consultation or eval/treat? Might be a verbal order within the chart from the physician who performed the surgery or their PA? A lot I see just a hand written note and just bill 99231.


----------



## cindyt (Jul 31, 2013)

The anesthesiologist dictated the follow-up visit but did not include a request from another physician.  Based on the documentation the coders billed 99232.  However the physician is requesting we bill a 99221, stating this is a new patient to him.  Since the group provided the anesthesia for the patient's initial surgery and according to the medical documentation this is strictly a post operative pain management visit, can we legally bill using a new visit code?


----------



## dwaldman (Jul 31, 2013)

The below statement is from Supercoder, and it is consistent with my current understanding of the AMA suggestion of use of 99221-99223. That this code range is reported by the admitting physician and that physician's that are consulted to see the patient report 99251-99255 or 99231-99233. If you don't feel that there was consult requested but merely an eval/treat then I would use the subsequent hospital codes as you had mentioned you were  going to use. For Medicare, they do allow the use of 99221 if the criteria for the History, Exam, and MDM are met from physicians other than the admitting physician. The admitting physician is denoted by placing the AI modifier. CMS states if it is an initial evaluation or consultation that does not meet the minimum threshold requirements of 99221 than it would be appropriate to report 99231-99232 even though it is not a subsequent encounter. But again my understanding for a carrier that follow AMA guidelines and accepts consultation codes and does not recommend using 99221 in lieu of the consultation codes, it my understanding 99221-99233 code range is reserved for the admitting physician, and in the case that consultation is not supported by the documentation it seems to leave you with 99231-99233. Maybe other forum members more familiar with this scenario could add thoughts to your question

Below is from Supercoder 

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. 
____________________________________________________________________________

Here is from the  claims processing manual Chapter 12, CMS states: 

In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 â€“ 99223) or nursing facility care codes (99304 â€“ 99306).  

The requirements for 99221 are the following and the E/M service would need to be audit to see that it contained at least a detailed history, detailed exam, MDM-Straightforward/Low

99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:
•A detailed or comprehensive history; 
•A detailed or comprehensive examination; and 
•Medical decision making that is straightforward or of low complexity. 

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.




F.  Initial Hospital Care Service History and Physical That Is Less Than Comprehensive  

When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission.  Contractors pay the office visit as billed and the Level 1 initial hospital care code.  
Physicians who provide an initial visit to a patient during inpatient hospital care that meets the minimum key component work and/or medical necessity requirements shall report an initial hospital care code (99221-99223). The principal physician of record shall append modifier â€œ-AIâ€� (Principal Physician of Record) to the claim for the initial hospital care code.  This modifier will identify the physician who oversees the patient's care from all other physicians who may be furnishing specialty care.  
Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT consultation codes (99241 â€“ 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements.  Physicians must meet all the requirements of the initial hospital care codes, including â€œa detailed or comprehensive historyâ€� and â€œa detailed or comprehensive examinationâ€� to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.  
Subsequent hospital care CPT codes 99231 and 99232, respectively, require â€œa problem focused interval historyâ€� and â€œan expanded problem focused interval history.â€�  An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232.  Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 â€“ 99255) prior to January 1, 2010, 
where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.  
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.  

G.  Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission  
In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 â€“ 99223) or nursing facility care codes (99304 â€“ 99306).  Contractors consider only one M.D. or D.O. to be the principal physician of record (sometimes referred to as the admitting physician.)  The principal physician of record is identified in Medicare as the physician who oversees the patient's care from other physicians who may be furnishing specialty care.  Only the principal physician of record shall append modifier â€œ- AIâ€� (Principal Physician of Record) in addition to the E/M code.  Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.


----------



## dwaldman (Jul 31, 2013)

it my understanding 99221-99233 code range 

In the above sentence I meant 99221-99223


----------



## arbucklej (Sep 17, 2015)

In the context of post op pain management, you are saying it is ok if the anesthesiologists bills a subsequent E/M if he sees the patient but doesn't do a procedure?


----------

