Question Initial Hospital Care codes and Admission to Hospital dates?

carlystur

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We've had an error pop up on some claims in ECW when we use initial hospital care codes on dates that are not the date of admission to a hospital. Should we be using subsequent hospital care codes or could correct coding be to use initial hospital care codes even though the visit by our provider wasn't on the date of admission?

For some context, I was told by a coder who used to work where I do while she was still working here that it was okay to do that and that's what I have done ever since - even while getting this ECW error. I was just told to ignore the error. I've not been the one to submit any hospital charges that any of our providers do. We used to have a biller who would submit all of our charges (hospital, facility, and clinic), but she left, and now we have another person who submits only hospital charges while I still code the hospital E/Ms and is giving me back the claims that show this error message: "99221 must have the start and ending service dates same as the Admission Date" and then the date of the patient's admission to the hospital. She sent me the two most recent ones I have done that give this error message and they are from almost 2 weeks ago.

Any thoughts or advice would be greatly appreciated!

EDIT: I reread the guidelines/lay term tips on using initial hospital care codes using our company's Codify and saw it said that only the admitting physician can use initial hospital care codes and "When a physician from a different specialty than the admitting physician sees the patient, then that physician can report the service separately." I'm assuming that's still on the same date as the date of admission?

Here's my issue. I have a provider who did a Detailed History, Comprehensive Exam, and Low MDM. If the provider was the admitting physician, then I would use 99221 or 99253 - depending on whether patient has insurance or is self-pay. This provider is rarely the admitting physician and was definitely not the admitting physician in this particular case. So, would I use 99233 instead for the Detailed History and Comprehensive Exam? My guess is yes, but the Low MDM has been throwing me off.
 
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mconner001

Networker
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We use the 99221 - 99223 codes when we are NOT the admitting physician. The admitting physician is supposed to be using the ai modifier so that other specialists can get paid. There is an old post about this modifier but I believe the information is still correct. Hope that helps.
 

csperoni

True Blue
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If you did an inpatient consult, but the carrier does not accept consult codes, the Medicare guideline specify you may use initial inpatient 99221-99223. They also state if you do not meet 99221 (since initial requires all 3 elements), you may use subsequent 99231-99233.
Not all carriers follow that same guidance about using 99221-99223 if you are not the admitting and want subsequent codes 99231-99233. Almost all of our contracts specify to use Medicare guidelines.
This is one of those situations where you follow the carrier policy.
Here are some CMS references when they did away with consult codes.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1875cp.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf
Specifically:
"In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306)."

In your example of detailed history, comprehensive exam and low MDM, I would code 99221 unless the carrier does not follow the Medicare guidance. I would wind up with 99233 with the caveat that you do not require MDM to be one of the 3 elements. If so, with low MDM, you are left with 99231.
Just think - depending on the carrier and/or your internal company policy, this 1 visit could be 3 different codes.
 
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