General Surgery Coding Alert

Question: One of my physicians was asked to see a patient in a nursing home. We reported 99244 with a place of service 32. Medicare denied the claim. Any suggestions?

Arkansas Subscriber

Answer: The carrier is correct to reject the claim. The CPT code and place of service do not match.

CPT specifically notes that office or other outpatient consultation codes (99241-99245), including 99244 (Office consultation for a new or established patient ...), "are used to report consultations provided in the physicians office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care, or emergency department." Place-of-service indicator 32, in contrast, denotes an inpatient facility (specifically, a nursing facility) as the site of care.

Initial inpatient consult codes (99251-99255) "are used to report physician consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting," according to CPT, and you should report them with a 32 place-of-service indicator. Assuming your documentation supports a level-four consult, the correct code in this case is 99254 (Initial inpatient consultation for a new or established patient ...). Similarly, report any follow-up consultations with the same patient using follow-up inpatient consultation codes (99261-99263).

Codes 99301-99316 also describe services provided to nursing facility patients. If the physician conducts an initial assessment of a patient entering a nursing facility to establish a medical care plan, the appropriate code is generally 99303 (Evaluation and management of a new or established patient involving a nursing facility assessment at the time of initial admission or readmission to the facility ...).

For annual care plan recertification, report 99301, and for reassessment when the patient incurs a permanent change in condition, report 99302. Codes 99311-99313 and 99315-99316 describe daily care and discharge services at various levels of complexity, respectively. Note that you should use the nursing facility codes only when the physician provides ongoing care and otherwise does not meet the requirements of a consult (request, reason and response).