Inpatient Facility Coding & Compliance Alert

Ensure the “inpatient” status before billing.

You cannot afford to do without this consult coding advice, when a physician provides a consultation in a hospital setting, including accident/emergency situations, or plays a role during the inpatient admission. Here is a lowdown on what you would need to know.

1. Site of Service Decides Patient Status

Make sure the patient the physician attends has been admitted as an inpatient; and remember that not all facility settings qualify as “inpatient” status. 

Example: Even if the doctor saw the patient in the hospital, the ED (emergency department), for instance, is an outpatient setting, and doctors provide consultations in the ED all the time.

Inpatients include patients admitted to hospitals, partial hospital settings or nursing homes. For inpatient services in a hospital, you can report from the code range 99221-99239 (Hospital Inpatient Services). For nursing home settings, you should choose from the code range 99304-99318 (Nursing Facility Services).

Caution: The physician’s consultation within the ED or for patients admitted to observation status, as well as for residents of domiciliary, rest (boarding) homes, custodial care or other non-skilled facilities are not inpatient services. Therefore, any codes from the 99217-99226 (Hospital Observation Services), 99281-99288 (Emergency Department Services), or 99324-99340 (Domiciliary, Rest Home [eg, Boarding Home]…) in the inpatient documentation should alarm you.

2. Distinguish Between “Admission” and “Consult”

Many coders think they can bill for an initial inpatient visit just because the doctor performed a history and physical exam in the office before admission. Because he dictated the history and physical for the patient without a face-to-face visit in the hospital, the doctor may think the he can bill an initial inpatient visit, but this is not true.

Example: A 65-year-old patient presents to the outpatient office location with abdominal pain, fever, nausea, and vomiting that started a few days before the visit. The physician decides after performing a comprehensive history and physical examination that the patient needs to be admitted as she is dehydrated and may have diverticulitis.

He advises admission to the hospital for intravenous antibiotics, fluids, and further testing. In this scenario, you should report the admission and not the initial office visit beforehand. You will report the admission with initial hospital care codes (99221-99223) and not E/M codes (99201-99205, New Patient Office or Other Outpatient Services). The admitting physician is considered “the physician of record” and has to use the initial services code with a modifier AI (Principal physician of record). Only the admitting physician may file a claim for the initial hospital visit using the AI modifier.

Plus: When a physician performs an initial visit on a Medicare patient in the hospital, you should use an initial hospital code from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…), according to Medicare’s consultation guidelines.

Example: If the doctor performs a detailed history, comprehensive exam, and straightforward medical decision making on a Medicare inpatient, you’ll choose 99221 instead of reporting an inpatient consult code (99251-99255) for this patient. The inpatient consultation codes are no longer accepted by Medicare but can be used for non-Medicare patients.

Remember: All other same-day submitted claims for initial hospital care codes will presumably be consultations. 

“Specialists who are requested to perform an inpatient consultation (initial or subsequent) will have to use the hospital visit codes but without the AI modifier,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. If no physician uses the modifier AI, or more than one doctor tries to bill for initial hospital care (99221-99223), the claim will most probably be subject to medical review and other claims may also stand the danger of “pending review.”  Abbey advises that “physicians, both admitting and consultative, must be very careful about their respective roles and the associated coding and billing.”