Not qualifying for 99221?

deumont

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Fayetteville, Pennsylvania
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Hello,

I've recently been informed that my one provider is not meeting criteria to bill a 99221, as he is only meeting EPF history/exam. What am I supposed to bill those instances as when he does not meet the 99221?

Thanks for your input
 

thomas7331

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If this is for a consultation service being billed to Medicare, you can code the service using a subsequent inpatient visit code:

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/MM7405.pdf

If this is for the admitting provider, there hasn't been a definitive guideline issued on this, that I know of. I think some MACs have asked that this be billed with the unlisted E&M code 99499, but I do know that some provider groups also use the subsequent inpatient care codes for the admitting provider as well. In actuality, the admitting provider probably really is performing at least a detailed exam though in order to meet the hospital's H&P requirements to admit a patient, so this is something that likely can be solved with some basic provider education on documentation requirements.
 
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