Wiki In-pt E/M question

[Richard Sigler]

Hello,
I work in orthopedics and of course my dr's are on call at the local hospital. I have some questions about in-patient hospital visits. On occasion the dr's are asked to evaluate a patient that will not need surgerical care and as a result I will code 99221-99223 due to the fact that the dr I am billing for is a orthopedic specialist that is preforming their initial evaluation. There has been some talk about using codes 99231-99233 no matter if its a first or subsequent visit because the patient has been admitted already. Is there anyone here with maybe more experience with this type of coding that might be able to add more information?

 

[Naveen Rachagolla]

In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). The principal physician of record is identified in Medicare as the physician who oversees the patient's care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier AI, Principal Physician of Record, in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.

In the office or other outpatient setting where an evaluation is performed, physicians and NPPs shall use the CPT codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. All physicians and NPPs shall follow the E/M documentation guidelines for all E/M services. These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer, because Effective January 1, 2010, the consultation codes are no longer recognized for Medicare part B payment except for inpatient telehealth consultation G-codes.

 

[MnTwins29]

Since this is the initial visit by the orthopedic specialist, it would be appropriate to use 99221-99223 if the payer does not recognize consultation codes. This is the initial visit by that physician for this patient's treatment. However, these codes require at least a detailed history and examination. If the documentation does not support a detailed or comprehensive history and exam, then the subsequent hospital visit codes of 99231-99233 may be used. It is best to check the particular payer's guidelines before doing so.