Wiki Does an initial inpatient visit need to be billed before subsequent visit?

[scrawford1690@gmail.com]

Hi!

I think the doctors I code for think they found some kind of loop hole. They've quit charging initial visits and are charging subsequent inpatient visits. I know this is wrong, but does anyone have an article where it clearly states this so I have proof?

I appreciate your help!

 

[amyjph]

They may be mistaking the old way for the new process. Prior to 2023, there were times when it would be a choice if they couldn't make the level of the lowest 9922_ so you would default to subsequent. That's not the same now. In your example, it would be initial.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

This helps: https://www.aapc.com/blog/86922-coding-inpatient-and-observation-visits-in-2023/

 

[amyjph]

That's not necessarily incorrect. There have been many times I have coded subsequent hospital visit and not initial. It depends on a lot of factors/scenarios. I would suggest reading the Hospital Inpatient/Observation and Subsequent Hospital Inpatient sections in CPT. Also, read the CMS manual. There is a specific direction in CPT where it instructs that a consultant would not report the initial and they report subsequent. It can also depend on the site the patient was admitted from, who else saw them and who is the admitting.

https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf

 

[scrawford1690@gmail.com]

Thank you for the information!

That makes sense, and i should have been more specific. This patient had not been seen by any other doctor, was not admitted from observation or outpatient status, did not have a procedure on a prior date. The visit was the first time the patient was seen in the hospital for the problem addressed by the provider of this specialty. Would they still be able to code this as a subsequent visit?