Wiki Initial Hospital Services that don't meet 99221

[rachelacosta72]

I was taught that if either the history or exam does not meet the level required for the lowest level of initial hospital service you were to code a 99499 (Unlisted Medicine Code). The hospital I work at now, bills a subsequent hospital code instead. Thoughts?

 

[Lloie]

It is ok to bill the subsequent code -

Here is what it says in the CMS manual.

Contractors shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

Unlisted evaluation and management service (code
99499) shall only be reported for consultation services when an E/M service that could be
described by codes 99251 or 99252 is furnished, and there is no other specific E/M code
payable by Medicare that describes that service.

Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual. T he principal physician of record is identified in Medicare as the physician who oversees the patient's care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” (Principal Physician of Record), in addition to the E/M code.

Hope that helps

 

[rachelacosta72]

Thanks! I kept digging after I posted and found the same reference! Feel much better that we aren't doing anything wrong.

 

[Naveen Rachagolla]

It is ok to bill the subsequent code -

Here is what it says in the CMS manual.

Contractors shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

Unlisted evaluation and management service (code
99499) shall only be reported for consultation services when an E/M service that could be
described by codes 99251 or 99252 is furnished, and there is no other specific E/M code
payable by Medicare that describes that service.

Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual. T he principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” (Principal Physician of Record), in addition to the E/M code.

Hope that helps

Hi Lloie,

Can you provide me that Document or the link, the one which your talking about CMS Manual, Because i went in search of that statement, in cms manual chapter 12, but i dint find. that if the services that are performed are not meeting the level 99221 then we can use sub-visit hospital codes.

 

[MnTwins29]

Pub 100-04, chapter 12, section 30.6.9.1

Here is the statement from the above refereneced section - payment for initial hospital care services:

Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

This was added when CMS decide to no longer pay for consultations so that consulting MD's could still get reimbursed for appropriate services to inpatients that may not have met the criteria for initial inpatient visits.