Wiki Hosp Consult E/M Question

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torih@nwurology.com

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One of my Urologists was asked to consult on an inpatient who has Medicare. The patient didn't speak English so the entire history was obtained from the chart and from conversation with the referring provider. My doctor did perform a detailed exam. Am I still able to bill this as an inpatient new patient? Because the patient has Medicare, I'm trying to remember if there are restrictions.

Thank you,
Tori
 
If I were auditing the record, I would be looking for a statement describing the patient did not speak English and the history was obtained from [specified source] to support any history. As long as there was sufficient elements to support a detailed history and the MDM information supports the level you were reporting; you would use an Initial Admit code 99221 probably.

There is no such thing as a New Initial inpatient code, FYI.
 
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