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darla190@hotmail.com

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We are seeing many insurances deny our inpatient visits.
Our MD's are usually not the admitting MD for the patient; the admitting MD is usually the hospitalist.
Is modifier 25 appropriate to append to our code?
Thank you,
Darlene
 
What is the reason for the denial? Modifier 25 is only appropriate if documentation supports the modifier definition, i.e. that your physicians are performing a significant, separately identifiable E&M service on the same day as a procedure by that same physician. Otherwise, it's not appropriate.

If your payers are denying the claims because other physicians of different specialties are seeing the patient on the same day, that is a payer error and likely not going to be avoided by adding modifiers - you'll need to address this with the payers or else review their policies for additional guidance.
 
Can someone please help me understand this better: Split (or Shared) Evaluation and Management visits for CY 2022. My NP's usually admit and work up a new patient in the IP setting prior to my hospitalists seeing the patient. How do we now document this? Do we need to have them add their time spent F2F with patient? How do we bill our shared/split billing?
r11115cp.pdf (cms.gov)
 
Hi Lauren
We do split share visit at our hospital. First the nurse does their portion before assigned to NP, or PP or MD. The nurses must do their note with, vitals taken and nature of complaint, then ROS. Next the MD, NP, PA put down their HPI, and check current meds, plus MDM rationale or M.E.A.T. and list assessment and dx codes. They put down all this in their notes on pt.. This should be a face to face visit. Modifiers used for the N Practitioner is NP and the modifier for the Phys. Assistant is AS. Ensure the docs put down the diagnosis code/assessment. Nurses can bill for 99211 if vitals taken and face to face. It seems on the templates nurse does her part first, and doctor can use this to aid him in treating pt but he must still do his notes/template on the patient HPI and review pt s medications. All set up in the EMR templates.

Since COVID 19 pandemic we have done a lot of telehealth (video or phone calls). The telehealth visit CPT are 99414 to 99444 phone calls by NP, MD or PA. The time must be put on the record as provider stating in words spoke with pt. for so many minutes, plus verified the patient's demographic information on each record. If Nurse or Techs call patients they use 98966 CPT codes. We add modifier 95 if video online visits using the Eval Mgnt CPT office codes plus time listed on record.. I am not in billing dept. but I ensure CPT and Dx codes are correct after reading the documentation. Each nurse has claim with her notes attached CPT 99211 or 98966 per documentation. Then get another claim from the MD,NP or PA notes attached with CMS 1500 claim. All this for same patient same date./time period. I do think despite these claims made, it is all billed under the main Medical Doctor's NPI linked on special field on CMS 1500 claim.
Do not use modifiers 52 or 25 on these split share claims if phone or video visits. Each state law varies but this is what I read that certified and licensed personnel under doctor's guidance can bill this split shared visits. Oh I read some of this data out of the Medical Record Auditor book 4th edition, pg 358 by Deb Grider but also from my own current work experience.

I hope this helps you.
Lady T:)
 
laurenelizabeth said:
Can someone please help me understand this better: Split (or Shared) Evaluation and Management visits for CY 2022. My NP's usually admit and work up a new patient in the IP setting prior to my hospitalists seeing the patient. How do we now document this? Do we need to have them add their time spent F2F with patient? How do we bill our shared/split billing?
r11115cp.pdf (cms.gov)
Click to expand...
Hi there, because billing is based on who performs the "substantive portion" of the visit, your physicians and NPs will both need to document the visit in a way that allows someone to determine who performed the substantive portion. If your practice uses the time-based method both providers need to document the individual time they spend on the qualifying activities listed in the change request for each patient on the date of the enounter. Those activities include face-to-face and non-face-to-face activities. When the physician spends the most time for a specific patient, bill under the physician's NPI. When the NP spends the most time, bill under the NP's NPI.

BTW, there's at least one webinar scheduled for this www.codingbooks.com/ympda012622 and MACs are starting to do presentations as well.
 
I am having a hard time understanding what category to code the E/M on an inpatient E/M when the providers want to document consult codes when almost all insurances don’t accept them. My providers are not the admitting providers so which category do I convert them to? I specialize in Cardiac such as pacer checks, reveals, TTE, TEE, stress tests, cardio versions and so on.
 
Watkins.Jess said:
I am having a hard time understanding what category to code the E/M on an inpatient E/M when the providers want to document consult codes when almost all insurances don’t accept them. My providers are not the admitting providers so which category do I convert them to? I specialize in Cardiac such as pacer checks, reveals, TTE, TEE, stress tests, cardio versions and so on.
Click to expand...
If the payer doesn't accept consult codes, and the provider is not the admitting, you go to the subsequent hospital care codes. Read the CPT book guidelines at the start of the Initial Hospital Care section, it explains what to do.
 
Actually, if you did a consult, but the carrier does not accept consult codes, the Medicare guideline state you may use initial inpatient 99221-99223. However, not all carriers follow that same guidance and want subsequent codes 99231-99233. Almost all of our contracts specify to use Medicare guidelines.
This is one of those situations where you follow the carrier policy.
Here are some CMS references when they did away with consult codes.
Specifically:
"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)."
 
csperoni said:
Actually, if you did a consult, but the carrier does not accept consult codes, the Medicare guideline state you may use initial inpatient 99221-99223. However, not all carriers follow that same guidance and want subsequent codes 99231-99233. Almost all of our contracts specify to use Medicare guidelines.
This is one of those situations where you follow the carrier policy.
Here are some CMS references when they did away with consult codes.
Specifically:
"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)."
Click to expand...
Good point, agree it depends on the payer. I was specifically referencing CPT.
It is also possible the provider would have to report the subsequent which require 2/3 key components rather than 3/3 if they don't meet the minimum requirement for a 99221. Depends on the documentation. See below, that section talks about it:

Claims Processing Manual, Chapter 12, 30.6.9.1, - Payment for Initial Hospital Care Services and Observation or Inpatient Care Services, F. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive
 
amyjph said:
Good point, agree it depends on the payer. I was specifically referencing CPT.
It is also possible the provider would have to report the subsequent which require 2/3 key components rather than 3/3 if they don't meet the minimum requirement for a 99221. Depends on the documentation. See below, that section talks about it:

Claims Processing Manual, Chapter 12, 30.6.9.1, - Payment for Initial Hospital Care Services and Observation or Inpatient Care Services, F. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive
Click to expand...
Yes, exactly. For Medicare, you MAY use initial. Not MUST use initial. I use initial whenever possible as there is typically a higher value (even if a lower level). The highest subsequent (99233) and lowest initial (99221) are valued very similarly. But if history, exam or MDM falls short of 99221, you can use subsequent.
Almost all my contracts specify Medicare guidelines, so we have the possibility to use initial even if not the admitting.
 
csperoni said:
Actually, if you did a consult, but the carrier does not accept consult codes, the Medicare guideline state you may use initial inpatient 99221-99223. However, not all carriers follow that same guidance and want subsequent codes 99231-99233. Almost all of our contracts specify to use Medicare guidelines.
This is one of those situations where you follow the carrier policy.
Here are some CMS references when they did away with consult codes.
Specifically:
"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)."
Click to expand...
Does anyone have a good reference to what LA MCD wants in this situation?
 
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