EM Coding Alert

Don’t rely on hospital E/M codes until you confirm inpatient status.

Picture this: Another physician needs your ob-gyn’s opinion on a hospital patient’s condition. Your physician examines the patient and shares their opinion with the treatment team, then creates thorough documentation regarding the encounter. Although the scenario doesn’t sound particularly complicated, it can lead to myriad coding questions and pitfalls if you don’t apply the right coding guidelines.

Follow these five steps to avoid common inpatient consultation coding pitfalls and set your practice on the right path toward compliance and reimbursement success.

1. Determine Patient Status via Site of Service

First, determine whether your ob-gyn (or another provider) has admitted the patient as an inpatient. The reason is that not all facility settings, or for that matter patients that appear to be “admitted” — qualify for “inpatient” status. Even if the doctor saw the patient in the hospital, the emergency department (ED), for instance, is an outpatient setting, and doctors provide consultations in the ED all the time. Similarly, a patient on a floor may be in observation, and here, too, an inpatient consultation code would not be the appropriate choice.

Inpatients include patients admitted to hospitals, partial hospital settings, or nursing homes. For inpatient services by your provider, that are not consultations, in a hospital, you can report a code from the code range 99221-99239 (Hospital inpatient services). For nursing home settings, you should choose from the code range 99304-99318 (Nursing facility services).

Caution: Your physician’s consultation in the ED or for patients admitted to observation status, as well as for residents of domiciliary, rest (boarding) homes, custodial care, or other nonskilled facilities, are not inpatient services.

Therefore, any codes from the 99217-99226 (Hospital observation services), 99281-99288 (Emergency department services), or 99324-99340 (Domiciliary, rest home (eg, boarding home)…) in the inpatient documentation should get your alarm bells ringing.

2. Don’t Confuse Admission and Consult

Many coders think they can bill for an initial inpatient visit just because the doctor examined the patient in the office before admission. Because the ob-gyn physician dictated the office visit requirements for the patient without a face-to-face visit in the hospital, the doctor may think the practice can bill an initial inpatient visit, but this is wrong.

For example: A 21-year-old established patient presents to the outpatient office location with pain, fever, nausea, and vomiting that started a few days before the visit. The ob-gyn decides after performing a level-four E/M visit (99214), that the patient needs to be admitted as it appears via ultrasound that she may have an ovarian torsion event.

The doctor advises admission to the hospital for intravenous antibiotics, fluids, and further testing. They then see the patient upon admission to the hospital and completes the visits. The documentation written in his office can be referenced in the inpatient note and then used toward the billed service level. In this scenario, you should report the admission and not the initial office visit beforehand. You will report the admission with initial hospital care codes (99221-99223) and not E/M codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient…).

The admitting physician is considered the “the physician of record” and has to use the initial services code with modifier AI (Principal physician of record). Only the admitting physician may file a claim for the initial hospital visit. If, however, the physician does not see the patient in the hospital, then you would bill the office service. Then, when the doctor does see the patient in the hospital the next day, they could bill the initial visit code.

When a physician performs an initial visit on a Medicare patient in the hospital (or to a patient whose payer follows Medicare guidelines), you should use an initial hospital code from 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 ...), 99222 (... comprehensive history; a comprehensive examination; and medical decision making of moderate complexity ...), or 99223 (... comprehensive history; a comprehensive examination; and medical decision making of high complexity ...), according to Medicare’s consultation guidelines, as Medicare and the payers that follow CMS guidelines no longer recognize the consult codes (99241-99245 or 99251-99255).

For instance, if the provider performs a detailed history, comprehensive exam, and straightforward medical decision making on an established Medicare inpatient, you’ll choose 99221 instead of reporting an inpatient consult code (99253) for this patient. The inpatient consultation codes are no longer accepted by Medicare but can be used for non-Medicare patients, depending on private payer policies.

3. Remember: ‘Initial’ Means Once

If you are sure that the patient is a qualified inpatient and their insurer recognizes consultant codes, you should choose an appropriate-level initial inpatient consultation code from 99251-99255 (Initial inpatient consultation services) for the physician’s first meeting with the patient requested by another provider. Don’t forget to check for the relevant documentation needed to support and qualify a consultation.

Caution: You can report 99251-99255 only once per patient per hospital stay.

For example, the attending physician requests that your physician provide a consultation for a hospital inpatient recovering from surgery and complaining of vaginal bleeding (N93.8, Other specified abnormal uterine and vaginal bleeding). The physician conducts a full history and examination. They document the consult request, prepares a report of their findings, and shares them with the managing (requesting) physician in the hospital chart.

In this case, you may report an initial inpatient consult code (such as 99251, Inpatient consultation for a new or established patient…), as well as any diagnostic tests the consulting physician provides.