E&M Coding: New vs Established

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Hello Friends!

I have recently been asked for some clarification on how we do E&M coding for an inpatient setting. We are an infectious disease specialty clinic and are called in for consultations. Sometimes it is a patient that we have already seen in our clinic, and the consult is for the same reason we were treating them. Sometimes that patient will need a consult for something completely different.

The debate is how to properly code for the consults. When I started working for the office, I was informed that we treat a patient as a "new" patient if the consultation is for something different that what we were seeing them for in the office. Example: A patient with TKA PJI was seen in clinic and is now in the hospital for infective endocarditis. I was also told to use 9922X for a new patient.

For these types of patients, would we use 9925X for the initial visit, then 9923X for the F/U's? A large portion of our patients are Medicare/Medicaid.

Some help from my "seasoned" friends would be greatly appreciated! Have a wonderful day!
 

CodingKing

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Reason for visit does not determine established vs new patient. If this were all outpatient and patient was seen in the last 3 years by a provider of the same specialty and same subspecialty in the same practice its established patient regardless of reason for treatment. Inpatient doesn't have a separate new vs established patient code. Its my understanding 9922X can only be billed by the Admitting/Attending Physician. Your physician would only use subsequent 9923X if not the attending/admitting.

Medicare ( I think Medicaid as well) you cant use the 9925X codes since they no longer accept consultation codes
 
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Thanks.

I just read up on CMS guidelines and they said they accept 9922X for initial consultation. So, what I am gathering now is that if we have already seen them in our clinic prior to them being admitted, we code 9923X. If we have not seen them and they are being seen for the first time consult, they get 9922X (Medicare/Medicaid). Other commercial insurance get the consult codes, though they do not translate into Medicare Secondary Payer. Does this sound anywhere near correct?
 
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CodingKing

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I believe what you are referring to is a patient being seen in the office and admitted in the same day. In a situation like that what happens in the office carries over to the admission (due to the 1 E&M per day rule) . I'll let some E&M expert chime in on the rest.
 
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Not really. They have been seen in our clinic for the same reason they are getting the consultation. Not on the same day as they were in the clinic.
 

mhstrauss

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The 9922X codes for Initial Inpatient E/M isn't the same as "new patient". If your physician was requested for a consult, (s)he can bill this code, regardless of whether or not the patient was seen before. The admitting doctor uses the same 9922X code, but with an AI modifier to indicate that they are admitting. In a nutshell, if a patient has commercial ins, you will use the 9925X codes for consult, then 9923X for followups. If the patient is Medicare (or any other payer that no longer accepts consult codes), use 9922X (provided that documentation supports the consult requirements) for the consult, then 9923X for followups.

HTH!
 

mitchellde

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If they are being seen in the inpatient setting for the same reason as in your office, then it will not be a consultation in the inpatient setting. You should use subsequent visit levels for all insurances.
 
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