General Surgery Coding Alert

Absent consult codes, CMS offers this solution for low-level initial care.

What should you do when the initial hospital care that you used to bill to Medicare using a consultation code doesn't add up to the lowest-level inpatient care code? That's been the million-dollar question since Jan. 1 when Medicare ceased accepting consultation codes (99241-99255, Office/Inpatient consultation for new or established patient ...). Now CMS offers a solution for when your general surgeon's initial hospital care doesn't meet the requirements of 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 ...).

Payers Should 'Overlook' Initial/Subsequent Mismatch

In an MLN Matters article (SE1010), CMS states that even when the provider documents an initial visit, Medicare contractors should "not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected)." Those codes include 99231-99233 (Subsequent hospital care ...)

Got that? Instructing folks to use a CPT code that doesn't exactly match the service meant that CMS reps were barraged with questions about the topic during an Open Door Forum (ODF).

Problem: "We recognize that there's not an exact match to the code descriptors for the low-level inpatient consult CPT codes to those of the initial hospital care CPT codes," noted CMS's Rebecca Cole during the ODF. "For example, 99251 and 99252 [Inpatient consultation for a new or established patient...] require a problem-focused history and an expanded problem-focused history, respectively, while 99221 requires a detailed or comprehensive history."

Solution: "Subsequent hospital care codes 99231 and 99232 require a problem-focused interval history and an expanded problem-focused interval exam ...[which] can potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by consult codes 99251 or 99252," according to Cole.

Yes, really: One caller expressed concern about submitting a subsequent care code despite documentation that her physician was visiting the patient in the hospital for the first time, but CMS reps reiterated the position. "If a subsequent hospital care visit works with respect to the intensity of the service and the level of the service, then it's okay to report [the subsequent hospital care code] if it's an initial hospital visit," a CMS rep confirmed.

Save Unlisted Code for Lowest Level

Prior to the MLN Matters clarification, Medicare administrative contractors (MACs) had offered differing advice about this problem, with some policies instructing you to bill an unlisted E/M code (99499, Unlisted evaluation and management service).

Different story: At the ODF, CMS told listeners to report 99499 only if the service doesn't meet the lowest level of subsequent hospital care -- "and we don't expect that would be very common," Cole said.

Don't worry about bell curves: CMS has alerted MACs to the fact that practices will be reporting more E/ M codes now that consults are eliminated, and that many physicians will be reporting more initial hospital care than in the past, Cole said.

Example: Suppose your general surgeon renders an opinion for a possible tracheostomy on a patient who is having difficulty breathing. The surgeon documents an expanded problem-focused history, expanded problemfocused exam, and moderate medical decision making.

Since the surgeon did not perform a detailed history and exam, which is needed for a 99221, you cannot submit an initial hospital care code, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. As a result of the lower-level history and exam that the surgeon did document, you should report 99232 per the instructions in MLN SE1010.

Because the subsequent visits only require two out of the three components, you should code the visit appropriately at a 99232, notes Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with the University of Pittsburgh Medical Center.

Don't miss: You may be able to bill 99233 in some cases since these codes only require two out of the three components. For example, a detailed history, problem-focused exam, and high medical decision making doesn't meet the requirements for 99221, but it does meet the requirements for 99233 since you "drop" the exam component and code using the other two components alone.