# Initial Hopsital code billing



## la_0922 (Sep 17, 2013)

I attended a Novitas-Solutions Webinar that specifically said that if the key components to an initial hospital visit (99221-99223) arent met, one cannot downcode to a subsequent follow up code unless it is a consult. My boss if asking for specific documentation that spells this out...I cannot find specifically where it says that only what I wrote down from the webinar....does anyone know where I can find this? 

help is very much appreciated!!!!

Louise


----------



## MnTwins29 (Sep 17, 2013)

la_0922 said:


> I attended a Novitas-Solutions Webinar that specifically said that if the key components to an initial hospital visit (99221-99223) arent met, one cannot downcode to a subsequent follow up code unless it is a consult. My boss if asking for specific documentation that spells this out...I cannot find specifically where it says that only what I wrote down from the webinar....does anyone know where I can find this?
> 
> help is very much appreciated!!!!
> 
> Louise



Is it possible to check the vaildity of this statement from Novitas?   The MLN Matters that addresses consults for inpatients, SE1010, does state that subsequent hospital visit codes can be used for the first encounter with an inpatient.   It does not state that the first encounter must be a consult.   This is taken directly from the MLN Matters bulletin:

How will Medicare contractors handle claims for subsequent hospital care CPT codes that report the provider's first E/M service furnished to a patient during the hospital stay?

A. While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code in cases 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.


----------



## RebeccaWoodward* (Sep 17, 2013)

If the requirements have not been met for the lowest level, admitting initial inpatient code, you report an unlisted E/M for the initial visit. The rules for "consultations" are a little different if the minimum requirements are not met.  See the FAQ below and view the difference.

Palmetto:

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

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

CMS:

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.

Q. How should providers bill for E/M services that cannot be described by any CPT E/M code that is payable by Medicare?

A. These services should be reported with CPT code 99499 (Unlisted evaluation and management service). Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment, and CMS expects reporting of this E/M code to be unusual.


http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/se1010.pdf


----------



## la_0922 (Sep 17, 2013)

thanks for the info and advice...I printed out the palmetto GBA website info, and I will call Novitas to verify also...thanks again!!! big help!!!


----------

