EM Coding Alert

Coding Quiz Answers:

Are You an E/M Expert? Get Your Answers Here

Published on Mon Oct 25, 2021

Rely on your MAC when deciding whether to use an unlisted E/M code.

Compare your choices to the answers below!

Question 1: Consider ‘Replacement Codes’ in Consultation Situation

If the physician performs a service for a Medicare patient that you would bill as an inpatient consult for a non-Medicare one, you should report 99221-99223 in place of 99251-99255. For outpatient consults, you should use either new or established E/M codes 99211-99215 or 99202-99205 (Office or other outpatient visit …).

Question 2: Know Whether Unlisted Codes are Appropriate

Unless the advice comes from a Medicare carrier, you should be very cautious about using an unlisted E/M code, experts say.

If the patient is considered an inpatient, you simply report an initial inpatient visit or a subsequent inpatient visit. Before using an unlisted procedure code in place of an E/M code, see the policy in writing from CMS. Some MACs have instructed practices to report the unlisted code if the documentation does not support any of the published E/M codes, but other MACs disagree. Therefore, you should only report codes that your MAC instructs you to bill, and be sure to use the MAC’s specific published criteria.

Question 3: Know Who Bills the AI Modifier

Not every physician who sees the non-Medicare patient in the hospital should append modifier AI (Principal physician of record).

The consultant’s initial visit should be billed with codes 99221-99223 without the AI modifier. The admitting physician utilizes the same codes but attaches the AI modifier.

If your ob-gyn sees the patient a second, third, fourth time, then he or she would utilize the subsequent inpatient care codes 99231-99233.

To eliminate confusion, you may want to retrain your brain to classify how you define the hospital care codes. A lot of coders think of the 99221-99223 range of codes as “admit codes,” when really they are actually initial hospital care codes.

Example: An emergency room (ER) doctor sees a patient who was involved in a motor vehicle accident. He calls in a trauma surgeon because of possible intra-abdominal damage, and the trauma surgeon admits the patient because of possible bleeding. The patient is pregnant, so an ob-gyn comes in for a consultation also. The trauma surgeon would report 99221-99223 with modifier AI appended.

The ob-gyn then bills 99221-99223 with no modifier.

Question 4: Rely on Documentation for Level Transfers

You should not simply transfer the level from non-Medicare patient consult codes to the office visit codes for a Medicare one. Instead, rely on the documentation to guide your code choice.

Example: If a physician follows AMA CPT^® guidelines for a consult in the office setting and documented (per AMA) a consult for an established patient that involved a detailed history, detailed examination, and medical decision making of low complexity, it would most likely qualify as a 99243 — which Medicare does not accept.

For Medicare patients receiving that same service, you’ll probably report 99203 if the consulting physician or another physician of the same group practice and specialty hasn’t seen the patient in the last three years.

If the patient was seen within the last three years, in most cases the claim would qualify for a 99214. The key is to match the key components performed or total time documented to the appropriate E/M code.

Click here to go back to the quiz.