EM Coding Alert

Inpatient E/M:

5 Steps Walk You Through Top-Notch Inpatient Consultation Coding

Published on Fri May 01, 2015

Know when to apply modifier AI for proper payment.

When your physician provides consultation services in the hospital, the coding is not always cut and dry. You’ll need to pay attention to place of service, follow-up services, and more to ensure your provider gets the reimbursement he deserves.

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. Site of Service Decides Patient Status

First, determine your provider (or another) 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 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). Payer requirements may also play a role that we’ll discuss later.

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 -non-skilled- 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. Keep in mind that only the admitting physician would use the observation codes; the consultant would use the outpatient (99201-99215 and possibly 99241-99245).

2. Distinguish Between “Admission” and “Consult”

Many coders think they can bill for an initial inpatient visit just because the doctor performed a history and physical exam in the office before admission. Because he dictated the history and physical 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 65-year-old patient presents to the outpatient office location with abdominal pain, fever, nausea, and vomiting that started a few days before the visit. The gastroenterologist decides after performing a comprehensive history and physical examination that the patient needs to be admitted as she is dehydrated and may have diverticulitis.

He advises admission to the hospital for intravenous antibiotics, fluids, and further testing. He then sees 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 (99201-99205, New patient office or other outpatient services).

The admitting physician is considered the “the physician of record” and has to use the initial services code with a proposed modifier AI (Principal physician of record). Only the admitting physician may file a claim for the initial hospital visit. If, however, he the physician does not see the patient in the hospital, then you would bill the office service. Then, when he does see the patient in the hospital the next day, he 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; comprehensive examination; and medical decision making of moderate complexity ...), or 99223 (... comprehensive history; comprehensive examination; and medical decision making of high complexity ...), according to Medicare’s new consultation guidelines, as Medicare and the payers that follow the guidelines, no longer recognizes the 99241-99245 or the 99251-99255 codes.

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.

3. Report Initial Consult Only Once Per Patient

If you are sure that the patient is a qualified inpatient, 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 rectal bleeding (569.3, Hemorrhage of rectum and anus). The physician conducts a full history and examination. He documents the consult request, prepares a report of his 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 (for example, 45330, Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).

Watch out: Don’t forget to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the consult code if the physician provides a same-day procedure (such as the sigmoidoscopy) or modifier 57 (Decision for surgery) if a major surgery is scheduled for that same day.

4. Keep Your Cool for Re-admissions and Follow-ups

You are in safe territory if the patient is discharged and later re-admitted because you can confidently report another inpatient consult if the condition of the patient is significantly different and medical necessity requires a full re-evaluation of the patient.

“Assuming all components of an inpatient consult are documented, then you may again report 99221-99223 for Medicare patients or 99251-99255 for non-Medicare patients. However, if the re-hospitalization does not require a complete re-evaluation by your [provider] but follow-up services are provided, then you should choose from the follow-up hospital visit codes 99231-99233,” instructs Michael Weinstein, MD, Vice President of Capital Digestive Care. Keep in mind that in the hospital setting these codes are initial visit codes, not new patient codes. They are used at each initial encounter.

Example: The patient in the above-given example leaves the hospital only to be re-admitted five days later. The managing physician finds that the patient’s previous condition has worsened and once again requests a consult from your gastroenterologist. You may again report 99251-99255, as appropriate.

In follow-up cases, as you cannot report follow-up inpatient consults, as CPT® deleted those code groups in 2006 now, you may choose from either 99231-99233 (Subsequent hospital care codes) for hospital inpatients or 99311-99313 (Subsequent nursing facility care) for nursing home inpatients for all subsequent care the gastroenterologist provides during the same inpatient stay.

5. Pick the Correct Coding Level

Just like the office setting, all notes must contain the information to substantiate the code level being submitted for the services rendered. “Unlike new office patient codes (99201-99205) and established office patient codes (99211-99215) where there are five coding levels, there are only three coding levels for initial hospital care codes (99221-99223) and the subsequent hospital care codes (99231-99233). The confusion is increased because the documentation and complexity of a ‘level 1 Initial Hospital Care code’ corresponds closely with a ‘level 3 New Patient Code,’” says Weinstein. “Only the most complicated hospital visits will necessitate a level 3 code (99223 or 99233), as these correspond to level 5 services. Hospital-visit coding and documentation has been a frequent target of Medicare audits and remains an area of risk for physicians who don’t follow the documentation guidelines for these services,” he cautions. 

Below are a couple of code examples to give you an idea on how to decide your coding level.

99221