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99221-99223

KaylaRieken

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Help. I have been told too many things on these codes. If my provider is not the admitting physician can he bill these codes for his consult for his initial visit? I have been told yes without the AI modifier and no you bill the 99231-99233 codes since most insurances do not accept the consult codes anymore. Which one is it??
 

csperoni

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Selden
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If you are the consulting, you may bill 99251-99255 if the carrier accept consultation codes, and you meet the other requirements for consult. If the carrier does not, I agree it is confusing as I have also found conflicting advice.
Per Supercoder under 99251-99255:
When an inpatient consultation is performed on a date that a patient is admitted to a hospital or nursing facility, all evaluation and management services provided by the consultant related to the admission are reported with the inpatient consultation service code (99251-99255). If a patient is admitted after an outpatient consultation (office, emergency department, etc), and the patient is not seen on the unit on the date of admission, only report the outpatient consultation code (99241-99245). If the patient is seen by the consultant on the unit on the date of admission, report all evaluation and management services provided by the consultant related to the admission with either the inpatient consultation code (99251-99255) or with the initial inpatient admission service code (99221-99223).
Per Supercoder under 99221-99223:
For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate.
In our practice, if not admitting & insurance accepts consult, we bill 99251-99255 for initial visit.
If not admitting & insurance does not accept consult, we bill 99221-99223 IF SAME DAY AS ADMISSION (no modifier), or 99231-99233 if different day than admission.
If admitting, 99221-99223 for initial visit with -AI.
Hope that helps.
 

KaylaRieken

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When I first started coding, the retiring coder said Medicare doesn't accept Consult codes so we as a group decided to bill the 99231-99233 codes for inpatients for everyone. So that is what I did for awhile. Then I started to ask questions and do some digging and was getting all sorts of different answers and am so confused. We are rarely the admitting physician, but do get called in to see the patient as I work for a urology group. Your information does help. Thank you for replying.
 

thomas7331

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I have never heard that the initial service must be on the date of admission, where is that information sourced from? The CMS guidelines on consultations state that it is the initial service should be billed with 99221-99223, but does not specify that this must take place on the date that the patient is admitted. Consultations frequently occur on dates of service following admission, so I don't know why the guidance would direct that the physicians should use codes that represent the work of a follow-up visit for an initial service.

Here is the guidance that was issued by CMS when the consultation codes were eliminated, which is still current:
 

twizzle

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Bradenton, FL
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Your provider can bill the 99221-99223 codes for his initial visit if the patient has Medicare or any insurance that doesn't accept consult codes (the majority) but without the AI modifier. This modifier is only used by one provider per admission to show they are the principle physician of record (admitting and/or attending). 99221-99223 documentation requires, at the very least a detailed history, detailed exam, and SF or low MDM. If neither the history nor exam meet detailed then you have to bill the subsequent IP visit codes 99231-99233 per the supporting documentation.

Of course, if the payer does accept consult codes and the criteria for a consult are met, then 99251-99255 would be the correct codes set to use.
 

KaylaRieken

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Thanks thomas7331. This is exactly what I started doing. The first time our provider sees the patient I bill the 99221-99223 without the AI because our physician is not the admitting. Then i would be the 99231-99233 for the subsequent visits.
 

KaylaRieken

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Thanks twizzle. So i need to find and keep a list of insurances who still accept the consult codes and bill for those. I know I have asked this question before about these inpatient codes and I feel everyone has different answers. It's hard to know what is the right way.
 

csperoni

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Selden
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I have never heard that the initial service must be on the date of admission, where is that information sourced from? The CMS guidelines on consultations state that it is the initial service should be billed with 99221-99223, but does not specify that this must take place on the date that the patient is admitted. Consultations frequently occur on dates of service following admission, so I don't know why the guidance would direct that the physicians should use codes that represent the work of a follow-up visit for an initial service.

Here is the guidance that was issued by CMS when the consultation codes were eliminated, which is still current:
My reference was copied & pasted from supercoder.com, which is the coding resource my employer provides. I don't know where they obtained their data.
I also recently saw someone else post that to bill 99221-99223, you MUST be the admitting, per CPT book definition (which of course I left in the office while working remotely). https://www.aapc.com/discuss/thread...t-meet-criteria.173273/?view=date#post-472959
 

csperoni

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I think this is one of those situations where CPT definition vs. CMS definition of things differ (like whether or not a surgical complication without return to OR is included in global).
CMS does advise, per Thomas' link above "In the inpatient hospital setting and nursing facility setting, any physicians and qualified NPPs who perform an initial evaluation may bill an initial hospital care visit code (CPT code 99221 – 99223) or nursing facility care visit code (CPT 99304 – 99306), where appropriate."
In my practice, because we are using the guidance in Supercoder (which could very well be incorrect, or only incorrect based on insurance) of billing 99221-99223 if visit is admit day, or 99231-99233 if not admit day, when not admitting physician and insurance does not accept consult codes.
There is absolutely conflicting advice on this, depending on the resource you use.
 

SharonCollachi

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Clovis, CA
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Well, this could also be why some of our admits get denied, saying someone else has already billed an admit. Then I have to appeal with our admission/H&P report, and fight tooth and nail to get paid.

We go by what the CPT book says, which is that 99221-99223 are for admitting physicians.
 

KaylaRieken

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Also how do you know if you follow Medicare guidlines or CPT guidelines for these insurances if you cant find anything on the website?
 
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Carson City, NV
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We are having the same confusion. What do you bill if the patient is in observation and a consulting physician is asked for a consult. the Provider is coding the IP initial and subsequent codes. Would those be billed under outpatient consult codes?
 

kfalcone

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Haskell, NJ
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99221-99223 are inpatient initial visit codes to be used if the consulting doctor is called to see an inpatient and their insurance does not accept consult codes. Then if the dr follows the patient up on a different day during that same hospital admission, 99231-99233 (inpatient followup codes) should be used.
** initial visit for that specific hospital admission. Inpatient codes do not matter if the patient is new or established to the doctor.
 

kfalcone

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Haskell, NJ
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We are having the same confusion. What do you bill if the patient is in observation and a consulting physician is asked for a consult. the Provider is coding the IP initial and subsequent codes. Would those be billed under outpatient consult codes?
If the patient is in observation and their insurance accepts consult codes, then you would bill 99241-99245. If insurance does not accept consult codes, then you would bill 99201-99205 (for new patients not seen by your specialty in last 3 years) or 99212-99214 for established patients (patients seen within your specialty in the last 3 years) .
 

SharonCollachi

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1,240
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Clovis, CA
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If the patient is in observation and their insurance accepts consult codes, then you would bill 99241-99245. If insurance does not accept consult codes, then you would bill 99201-99205 (for new patients not seen by your specialty in last 3 years) or 99212-99214 for established patients (patients seen within your specialty in the last 3 years) .
99201-99205 is not for use in the hospital setting.
 
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99201-99205 is not for use in the hospital setting.
99201-99205 includes "other outpatient visit" which observation falls under. I'd like to also add that a lot of carriers that I've worked with has stated the observation E/M codes are only to be used by the physician that admitted the patient to observation.
 
Last edited:

SharonCollachi

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Clovis, CA
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99201-99205 includes "other outpatient visit" which observation falls under. I'd like to also add that a lot of carriers that I've worked with has stated the observation E/M codes are only to be used by the physician that admitted the patient to observation.
The CPT book directs you to the ER visit codes, as those are the most specific available. I stand by my assertion that 99201-99205 is not for ER visits.
 
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