Wiki Initial Inpatient vs Inpatient Consult Code

[c7hill]

For non-Medicare payors (i.e Medicare or Commercial) are we to convert the Inpatient Consult Codes to Initial Inpatient (like Medicare) or Subsequent Hospital Care codes? Per the guidelines "For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate." If the non-Medicare insurance carrier does not accept consult codes, are we allowed to convert to an Initial Inpatient code, like Medicare?

Thank you,
Cindy Hill, CPC

 

[SharonCollachi]

The wording of your question almost sounds like someone is telling you that there is a law that says you cannot do something, and you're looking for a law that says you can ("are we to"... "are we allowed"). I may be completely misreading the situation.

If an insurance company does not accept consult codes, whether that is for inpatient or outpatient, you use the appropriate E&M code, just like you do for Medicare.

 

[c7hill]

The wording of your question almost sounds like someone is telling you that there is a law that says you cannot do something, and you're looking for a law that says you can ("are we to"... "are we allowed"). I may be completely misreading the situation.

If an insurance company does not accept consult codes, whether that is for inpatient or outpatient, you use the appropriate E&M code, just like you do for Medicare.

Thank you so much Sharon for your reply.

So, if our provider is not the admitting physician, they can still use the Initial Hospital Care code if the insurance carrier does not accept consult codes. Am I understanding correctly?

 

[twizzle]

Yes, you are understanding correctly. You would use 99221-99223 or 99218-99220 depending if the admission is IP or Observation respectively. For the IP scenario only you would add modifier AI if your provider was the admitting and/or attending physician who oversees the patient's care, as distinct from other physicians who may be furnishing specialty care.

 

[c7hill]

Yes, you are understanding correctly. You would use 99221-99223 or 99218-99220 depending if the admission is IP or Observation respectively. For the IP scenario only you would add modifier AI if your provider was the admitting and/or attending physician who oversees the patient's care, as distinct from other physicians who may be furnishing specialty care.

Thank you so much!

 

[SharonCollachi]

I have had claims denied for Initial Hospital Care (when we are not the admitting physician) by numerous insurances. We're running about 50/50 on whether a company will accept an Initial Code instead of a Subsequent Code.

 

[megg1100]

I have had claims denied for Initial Hospital Care (when we are not the admitting physician) by numerous insurances. We're running about 50/50 on whether a company will accept an Initial Code instead of a Subsequent Code.

Initial INPATIENT hospital care can be billed in place of a consult. However, initial OBSERVATION care can only be billed by the admitting physician. These must be converted to the applicable office visit code.

 

[SharonCollachi]

Initial INPATIENT hospital care can be billed in place of a consult. However, initial OBSERVATION care can only be billed by the admitting physician. These must be converted to the applicable office visit code.

We never do observation care, only inpatient hospital care. Sometimes we are the admitting; sometimes we are not. I remember at least once we were the admitting, but someone else billed an initial hospital code first, and ours was denied as the services were billed by another provider (or similar wording). I had to appeal twice with our admitting H&P report and a sternly worded appeal letter that no one else admitted this patient, and we expected them to rectify their mistake and pay us.

 

[megg1100]

We never do observation care, only inpatient hospital care. Sometimes we are the admitting; sometimes we are not. I remember at least once we were the admitting, but someone else billed an initial hospital code first, and ours was denied as the services were billed by another provider (or similar wording). I had to appeal twice with our admitting H&P report and a sternly worded appeal letter that no one else admitted this patient, and we expected them to rectify their mistake and pay us.

If you are admitting, I would use modifier -AI (principle physician of record) if you aren't already. That might help. However, as long as your physician is a separate specialty as the other physician billing initial inpatient care, it should be payable.

 

[SharonCollachi]

Yes, I know. What I'm saying is that with some insurance companies, it doesn't seem to matter - for them, only one physician can bill for initial hospital inpatient. So if claims get denied, use the subsequent codes.

 

[csperoni]

I believe the difference in opinion regarding this matter is a difference of CMS vs CPT definition of 99221-99223 codes.
CMS has issued guidance that IP consult codes are converted to 99221-99223. Modifier -AI if you are the admitting physician.
The CPT description of 99221-99223 specifies admitting physician.

Some insurances that no longer accept consult codes will use the CMS guidance and multiple physicians may bill 99221-99223. Other insurances will only accept 99221-99223 by one physician, and expect only the admitting to use 99221-99223; other physicians are expected to use 99231-99233. I personally have only had a handful of denials for this, and I appeal even if we are not the admitting. Only if the appeal denies will I use 99231-99233.