Wiki initial hospital visit but no exam?


Midlothian, VA
Best answers
I have a physician who was asked to perform an initial hospital visit on an elderly patient. When he got to the patient's room the family refused to let him wake the patient. He reviewed records, talked to the requesting physician and talked to the family.

We can't submit the initial hospital visit codes because there is no exam....
Any suggestions?
I was thinking:
99221-99223 if he documented how much time he spent and then billing based on time
99231-99233 since not all 3 key components are needed?

Thanks for any ideas you guys have!
99499 - Unlisted E/M

So he is NOT the admitting physician, but a "consulting" physician (who can't bill consult code because patient is on Medicare)?

IF the purpose of the discussion with family was for counseling/coordination of care, and if the physician spent at least 30 minutes at the bedside AND if at least 16 of those minutes was spent in counseling/coordination of care, AND if all this is clearly documented .... (lots of "ifs there) ... you can code the initial hospital visit using the time spent.

On the other hand ....

I would probably use 99499 - Unlisted E/M service (this is what we use when an intraoperative consult is requested and there is no exam there either).

One more question ... did physician come back later in the day to examine patient? If so, you can use ALL the documentation of services done in one date to arrive at your level of service.

Hope that helps.

F Tessa Bartels, CPC, CEMC
F Tessa,

Thank you so much! All the "ifs" you mentioned is why I was hestiant to use the 99221-99223 codes based on time.... we didn't have a few of those covered.

I'd never considered the 99499, thanks!

No he never went back and saw the patient, Dr. A was called on call at night to come see the patient. Dr. B from our group then saw the patient the next day during normal rounding hours.