Psychiatry Coding & Reimbursement Alert

Question: Doctor A admits patient from assisted care facility. Dr. B does the H & P for a patient that has a Medicare replacement policy on the following day. Can I bill for the Initial Hospital Care (99221-99223)? My understanding is that when a patient has a Medicare replacement, that since Medicare no longer pays consult codes, you can use an initial hospital care since we are a specialty and it was his first time visiting the patient in the hospital. Am I correct?

Michigan Subscriber

Answer: There isn’t quite enough info in your question to give you a straight yes or no answer, but here are some general guidelines to get you started in the right direction.

First, you don’t really say whether Dr. A actually did anything other than put a call in to say “admit the patient on my rotation.” If all he did was make a call and really didn’t perform a service, then Dr. A shouldn’t bill anything. But assuming that Dr. A performed and documented at least the minimum of a detailed history and exam as well as medical decision making, in that case, Dr. A would bill the proper initial hospital care code, 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI (Principal physician of record).

If Dr. B was called in to do an inpatient consult, which it seems your question implies, then yes, Dr. B would bill the appropriate initial hospital care code of 99221-99223 or subsequent hospital care code (99231-99233) that reflects the service provided. Typically, for the first encounter with the patient in the inpatient setting, this will be an initial hospital care code. Note that there still needs to be that documented request for a consultation even though you aren’t using consultation codes, because the 99221-99223 are really just in place of the consult codes. If Dr. B really just did an H&P without a request for a consult, then Dr. B should simply bill follow-up inpatient care (99231-99233).

Here’s why: Most Medicare replacements follow Medicare’s rules about no longer using the consultation codes, and using 99221-99223 instead the first inpatient encounter between a consultant and a patient. However, you should not assume that is the case. Check with your payer. Go to their website and search and see if you can find something in writing that states whether or not they accept the consultation codes still.

Also keep in mind that the two doctors should either be from separate practices or separate specialties in order to both bill an inpatient E/M service to the same patient on the same date. Typically, physicians of the same specialty in the same practice are treated as one physician for Medicare payment purposes, and the inpatient E/M services are considered “per day” services.