Dermatology Coding Alert

Published on Fri Jan 01, 2010 PDF

Best bet: Follow local guidance until more detailed info comes from Medicare.

If you've been confused about how to report low-level hospital visits now that consult codes are gone, you aren't alone. CMS intends to tackle this problem by issuing more specific guidance on the topic in the near future.

That's according to a Feb. 2 CMS-sponsored Physicians, Nurses, and Allied Health Professionals Open Door Forum, in which one practice asked the CMS reps when the agency plans to issue instructions on how to report initial hospital visits when the documentation doesn't meet the criteria for the lowest level visit, 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity ...).

CMS is currently working with the medical community to create such guidance, which will "hopefully be out shortly," noted CMS's Whitney May during the call.

One caller indicated that her MAC (WPS Medicare, a Part B insurer in Illinois, Michigan, Minnesota, and Wisconsin) instructed her to use the unlisted E/M code 99499 (Unlisted evaluation and management service) when the visit doesn't meet the criteria of 99221 -- but the MAC also said it would be inappropriate to report a subsequent care code (99231-99233) prior to an initial care code (99221-99223).

That interpretation basically says "that if you don't meet the initial care code, you have to bill unlisted, but the next day if you don't meet the initial care code you still can't bill a subsequent visit because you haven't billed an initial hospital care code, so you have to bill another 99499," the caller said. "I understand you're working on creating guidance on this issue, but what do we do today?"

A CMS rep advised the caller to follow local contractor guidance until CMS is able to issue a more detailed update. "We've been working closely with the medical community to try to develop very clear instructions for how to address this particular situation as well as some other questions that have come to us, and we are very close to having that information completed," the CMS representative said. "We want to be very sure when we're putting out information that we're putting it out only one time and that it's understood by everyone -- so that should be coming out very soon."

When asked whether the guidance would be issued in "days, weeks, or months," the CMS spokesperson responded only that CMS is doing its best "to get it out as soon as possible."