Wiki Denials with 99222/99223

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Mhutchins18

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I work for a multispecialty Clinic( Pulmonologists/Intensivist's/ Hospitalist's. We are getting denials( specifically from Aetna and BCBS) when billing these service's. The denials are stating that these codes can only be billed by the admitting doctors per AMA. We have billed these for both specialties currently and in the past with no other trouble from any of the other carriers . We have tried to research this to no avail. I was wondering if anyone else has run into this? Thank you.
 
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This could be a few different things.
1. Is the provider you are billing for the admitting physician of record?
2. If so, is the payer looking for the AI modifier?
3. Is the patient definitely IP and not observation or OP status?
4. Check the payer specific rules for the carrier you are trying to bill, they can vary.

This is a Medicare reference, the payers you mention may or may not follow the same guidelines, you would want to check their guidelines for the initial hospital care codes.
Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners Table of Contents (Rev. 10742, 05-03-21) 30.6.9.1 - Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)

If you read the CPT guidelines for 99221-99223 it might help guide you too: The codes are used to report the first hospital IP encounter w/ the patient by the admitting physician. For initial IP encounters by physicians other than the admitting you would report IP consult (if allowed by payer) 99251-99255 or subsequent hospital codes 99231-99233.

In my experience when working for a specialty practice we always had to check to see who actually admitted the patient for our inpatients. Occasionally our providers actually admitted but most of the time it was another provider. So we usually weren't able to capture 9922_ codes, it would end up being 9923_.
 
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amyjph said:
This could be a few different things.
1. Is the provider you are billing for the admitting physician of record?
2. If so, is the payer looking for the AI modifier?
3. Is the patient definitely IP and not observation or OP status?
4. Check the payer specific rules for the carrier you are trying to bill, they can vary.

This is a Medicare reference, the payers you mention may or may not follow the same guidelines, you would want to check their guidelines for the initial hospital care codes.
Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners Table of Contents (Rev. 10742, 05-03-21) 30.6.9.1 - Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)

If you read the CPT guidelines for 99221-99223 it might help guide you too: The codes are used to report the first hospital IP encounter w/ the patient by the admitting physician. For initial IP encounters by physicians other than the admitting you would report IP consult (if allowed by payer) 99251-99255 or subsequent hospital codes 99231-99233.

In my experience when working for a specialty practice we always had to check to see who actually admitted the patient for our inpatients. Occasionally our providers actually admitted but most of the time it was another provider. So we usually weren't able to capture 9922_ codes, it would end up being 9923_.
Click to expand...
Thought of something else too. Sometimes the hospital utilization review changes the status to observation when it may have been IP at first. Depending on how quickly you are coding these you may need to go back and make sure the patient's status did not change.
 
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All good advice above by @amyjph. If the patient is definitely inpatient and you are not the admitting, this is one of those situations where CMS guidelines may differ from other carrier guidelines. When CMS did away with consults, their specific advice was for the other consulting doctors to use 99221-99223. However, many commercial carriers will only pay the one admitting physician for the initial visit and require everyone else to bill 99231-99233.
Regarding Aetna and BCBS previously paying them:
1) Their policy may have changed.
2) The ones previously paid may be for Medicare Advantage plans which follow the CMS guideline, but the ones being billed now are for commercial plans and have different guidelines.
You have to check the carrier policy for the specific type of plan the patient has.
 
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We spoke with Blue Cross Commerical this week and they want the same codes that they used last year. 99252-99255 for inpt and then 99243-99245 for outpt. It has been a struggle this year getting claims paid with the new changes etc. Blue Medicare follows Medicare guidelines.
 
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