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Wiki E/M question on guidelines

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jlb102780

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Good Morning everyone :D

This scenario is for Medicare patients in an inpatient hospital setting:

I have a physician that seems to think that if he sees a patient in the hospital in the last 3 years, that he can only bill for a subsequent visit 99231-99233. I know about the 3 year rule on a new/est patient in the office setting, never heard of this applying to a patient in an inpatient setting. I have been taught that if the patient is admitted for a new complication that we have not seen the patient for, and we are consulted by the admitted physician, it is billed with the 99221-99223 codes without the "AI" modifier. I have tried to explain to the physician that if the patient is established and its an admission for an issue that is known, then we would bill the 99231-99233. Am I understanding this right? I've tried to find documentation on Medicare's website about this kind of scenario and I'm having a hard time. If anyone can send me a link that may help so I can show my doctor the correct way to bill these that would be great. :D
 
jlb102780 said:
Good Morning everyone :D

This scenario is for Medicare patients in an inpatient hospital setting:

I have a physician that seems to think that if he sees a patient in the hospital in the last 3 years, that he can only bill for a subsequent visit 99231-99233. I know about the 3 year rule on a new/est patient in the office setting, never heard of this applying to a patient in an inpatient setting. I have been taught that if the patient is admitted for a new complication that we have not seen the patient for, and we are consulted by the admitted physician, it is billed with the 99221-99223 codes without the "AI" modifier. I have tried to explain to the physician that if the patient is established and its an admission for an issue that is known, then we would bill the 99231-99233. Am I understanding this right? I've tried to find documentation on Medicare's website about this kind of scenario and I'm having a hard time. If anyone can send me a link that may help so I can show my doctor the correct way to bill these that would be great. :D
Click to expand...

New vs. Established Patient isn't the same as Initial vs. Subsequent Encounter...

You can have an initial visit with an established patient - the "initial/Subsequent" designation refers to the encounter at that particular site of service, for that particular admission - not necessarily whether or not the provider's ever seen the patient before. It looks like you understand the guidelines, to me. ;)
 
Thanks so much! That MRN article was actually what my doctors were given originally by our Admin office. They were reading the guidelines wrong thinking that the 3 year rule applied to hospital inpatient services. Thanks for the replies :D
 
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