EM Coding Alert

Question: On a recent claim, I used a CPT® code for subsequent hospital care to report my physician’s first E/M service with a new patient during their hospital stay. Will the claim be denied?

Massachusetts Subscriber

Answer: Keep in mind that the “new patient” concept does not apply in the hospital setting. If the physician was asked to consult on a patient with Medicare (or a payer that follows Medicare guidelines) and his documentation doesn’t support at least a 99253 (Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity…), then you could code the service as a subsequent service using the 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:…) range. 

The 99253 would convert to a 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…) for submission to the Medicare contractor.

If your physician was the admitting physician or taking over the care of the patient, then the code you submit should be from the 99221-99223 family. In those instances, it would not be appropriate to bill a subsequent visit.