Wiki Inpatient consults

[sharynwolfe]

So since Medicare no longer accepted the consult code, we were pointed in the direction of the Initial inpatient hospital care codes (99221-99223), however now the insurance companies that were following suite are now processing those codes as they are written, which is the first hospital inpatient encounter with the admitting physician. SO if my docs are consulted in an inpatient setting, what on earth am I supposed to charge?? A subsequent visit? Because it is subsequent to the initial encounter of another physician?? (this is the only logic I can come up with)

Any and all help would be much appreciated!!
Sharyn

 

[thomas7331]

Under Medicare rules, the admitting physician's initial visit must be billed with modifier AI in order to distinguish it from the initial inpatient codes that are billed by consulting physicians. Each specialty may bill an initial visit, and subsequent visits by the providers in that same specialty would be billed with subsequent care codes. You do not need to recode a consultant's initial visit as subsequent to the visit of the admitting provider since they would be of different specialties.

 

[sharynwolfe]

Under Medicare rules, the admitting physician's initial visit must be billed with modifier AI in order to distinguish it from the initial inpatient codes that are billed by consulting physicians. Each specialty may bill an initial visit, and subsequent visits by the providers in that same specialty would be billed with subsequent care codes. You do not need to recode a consultant's initial visit as subsequent to the visit of the admitting provider since they would be of different specialties.

*** Thomas, thank you for your response. I know what Medicare rules are, however Medicare Advantage plans do not have to follow Medicare rules, and they are proving that to us by not paying for 99221-99223 codes. I was hoping someone would have some insight into why or insight on what the heck we are supposed to charge when consulted in an inpatient setting for an initial visit. Thank you again - Sharyn

 

[thomas7331]

*** Thomas, thank you for your response. I know what Medicare rules are, however Medicare Advantage plans do not have to follow Medicare rules, and they are proving that to us by not paying for 99221-99223 codes. I was hoping someone would have some insight into why or insight on what the heck we are supposed to charge when consulted in an inpatient setting for an initial visit. Thank you again - Sharyn

Medicare Advantage plans DO have to follow Medicare rules, within certain limits. Medically necessary inpatient specialist consultations are a standard covered benefit that they are required to cover for eligible beneficiaries - they do not have a choice in this matter. If they are not following the CMS/Medicare rules for how to code these consultations, then they are required to have some written contractual or policy documentation to direct you as to how they require those services to be billed. Otherwise, the denials may be simple claims processing errors. I would recommend against changing your coding or charging something different simply because a plan is denying claims without first researching those policies and/or contacting the payer(s) in question and escalating the issue.

 

[sharynwolfe]

Medicare Advantage plans DO have to follow Medicare rules, within certain limits. Medically necessary inpatient specialist consultations are a standard covered benefit that they are required to cover for eligible beneficiaries - they do not have a choice in this matter. If they are not following the CMS/Medicare rules for how to code these consultations, then they are required to have some written contractual or policy documentation to direct you as to how they require those services to be billed. Otherwise, the denials may be simple claims processing errors. I would recommend against changing your coding or charging something different simply because a plan is denying claims without first researching those policies and/or contacting the payer(s) in question and escalating the issue.

*** Thank you again Thomas. I will push further with the 2 separate Medicare advantage plans that I am fighting on this. For the record, I have appealed and been denied this fight, which is why I asked the questions on here to see if anyone else is having this issue. I am seeing a trend here and I am at a loss as to how to fight it. I also asked a Medicare representative about this issue, to which I was told that the advantage plans do not have to follow Medicare guidelines to the letter. There are loop holes and I fear this is one of them. The insurance company hasn't said the patient isn't entitled to a specialist consult, they have said that I am billing with the wrong code. Thank you again!! I do appreciate the insight.

 

[sarab86]

I have run into this same issue regardless of the fact that Medicare Advantage plans are supposed to follow Medicare. The MA and Commercial plans have started following CPT strictly in 2018. CPT only allowed one Initial visit per admission and all other visits, regardless of the specialty are to bill a subsequent encounter visit. This was also reiterated in the CMPA course I took this year. Because of this I have been billing our Initial visits for these plans as level 3 subsequent visits. I have appealed and appealed and appealed this with absolutely no success. The only time I can bill Initial visit is if we were the admitting provider. Because my providers are Neurosurgeons, we are often called in the next day therefore the hospitalist gets the Initial visit billed before we are ever called.

 

[sharynwolfe]

I have run into this same issue regardless of the fact that Medicare Advantage plans are supposed to follow Medicare. The MA and Commercial plans have started following CPT strictly in 2018. CPT only allowed one Initial visit per admission and all other visits, regardless of the specialty are to bill a subsequent encounter visit. This was also reiterated in the CMPA course I took this year. Because of this I have been billing our Initial visits for these plans as level 3 subsequent visits. I have appealed and appealed and appealed this with absolutely no success. The only time I can bill Initial visit is if we were the admitting provider. Because my providers are Neurosurgeons, we are often called in the next day therefore the hospitalist gets the Initial visit billed before we are ever called.

YES!!!!!!!!!!!!!!!!!!!!! Thank you so much!!!!!!!!!!!!!!!!! I was starting to rethink my abilities!!! You have no idea how much I appreciate your response!! If and when I have a solid foundation on this... I will share.... thank you again!