E & M Visit, While Beneficiary Is Inpatient
E & M Visit, While Beneficiary Is Inpatient
Why do I have to bill an inpatient Evaluation and Management (E&M) service when the patient was brought to my office?
The Centers for Medicare & Medicaid Services (CMS)Internet Only Manual (IOM) Publication 100-04, Chapter 26, Section 10.5 states:
"When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility."
In addition, CMS IOM Publication 100-04, Chapter 6, Section 80.4 states, "For example, if SNF inpatients are taken to the private office of a neurologist for necessary tests such as an encephalograph, the services are considered performed in the SNF for billing and payment."
Based on the IOM references, the appropriate POS code to use when seeing a patient classified as a hospital inpatient is 21. For a patient in a covered Part A stay in the SNF, the POS is 31. The physician should choose the procedure code for the correct category of E/M services.
If performing a procedure, verify if there are differences between Current Procedure Terminology (CPT) codes for an inpatient and outpatient procedure. For example, if performing a diagnostic procedure such as a chest X-ray, the provider would bill the technical only component to the facility for payment. The professional component would be submitted to the providers Contractor/MAC for payment. For an E/M service, providers should choose a code from the inpatient hospital or SNF category of services.
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