When documentation doesn't meet 99221?

mgnitecka

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I was wondering if anyone has any information on what to do when an initial hospital visit does not meet the criteria of the 99221? Is it supposed to be downcoded to a subsequent (99231-99233) visit? I can't find any clear documentation on this issue.

Thanks!
 

ndhight

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99221 is for the first admittance visit then you would use 99231-99233 for subsequent visits. If patient is discharged same day use 99234-99236. Hope this helps.
nichole
 

mgnitecka

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Yes, but if the history doesnt even meet detailed what are the guidelines? Don't bill? Use unlisted code? Use subsequent??

Thanks
 

ndhight

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If this isn't the first day then you could use 99232 you only need to meet 2 of the criteria. Otherwise, use 99222.
 

mgnitecka

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It is the first day--admit to hospital. 99222 cannot be used for this because the history does not even meet detailed level.
 

rthames052006

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I was wondering if anyone has any information on what to do when an initial hospital visit does not meet the criteria of the 99221? Is it supposed to be downcoded to a subsequent (99231-99233) visit? I can't find any clear documentation on this issue.

Thanks!
I read an article in coding edge two years ago ( I know old reference) but after reading this thread I went back thru my old ones...

It was the Feb 2006 coding edge where they were discussing this very issue, it says " if the hsitory and/or exam are only problem focused or epf the initial hospital care codes cannot be used. If that is the case, the coder must use the unlisted e/m code of 99499 or a subsequent hospital care code; BUT... it is important to check with your individual payers to determine how they want this scenario coded."

We have had this happen in our practice and we have always contacted the payer to find out how they want it done, in my dealings with this scenario I've been told to code it as a subsequent visit by the carrier.

Have a good day,
 
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renifejn

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Contacting a Payer

I need to contact a payer to find out what I need to do in this situation, but have never done it before. Who or what department do I need to ask for to get an answer to this question from the carrier?

Thanks
 
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99499

I was just at a Billing/Coding Symposium put on by the Medical Society of Wisconsin. One of the panelists on the E/M presentation was from MediCare. He said they would expect to see 99499 - unlisted E/M if the key components don't equal at least 99221.

F Tessa Bartels, CPC, CPC-E/M
 

jllgood

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This was just published for Noridian Medicare

Medicare B News Issue 237 May 29 2007
Heading: Billing
Title: Unlisted Evaluation and Management Service CPT Code 99499
1. If an "inpatient admission" (99221, 99222, 99223 or 99291) is necessary, with all required components performed and appropriately documented, then that level of service is appropriate for billing and payment.

2. If criteria for even a 99221 "inpatient admission" are not met, but a service was necessary, and all of the required components performed and appropriately documented meet criteria for a "subsequent visit" (99231, 99232 or 99233), then that level of service is appropriate for billing and payment (even though the service is chronologically an "admission").

3. If, in what should be a very rare circumstance, an E&M service is necessary, performed and documented that does not meet even the criteria for a 99231, then a 99499 may be paid (which requires individual adjudication and pricing based on the submitted documentation).
 

cdcpc

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Do you have a link so I can see this info online?
Thank you!

This was just published for Noridian Medicare

Medicare B News Issue 237 May 29 2007
Heading: Billing
Title: Unlisted Evaluation and Management Service CPT Code 99499
1. If an "inpatient admission" (99221, 99222, 99223 or 99291) is necessary, with all required components performed and appropriately documented, then that level of service is appropriate for billing and payment.

2. If criteria for even a 99221 "inpatient admission" are not met, but a service was necessary, and all of the required components performed and appropriately documented meet criteria for a "subsequent visit" (99231, 99232 or 99233), then that level of service is appropriate for billing and payment (even though the service is chronologically an "admission").

3. If, in what should be a very rare circumstance, an E&M service is necessary, performed and documented that does not meet even the criteria for a 99231, then a 99499 may be paid (which requires individual adjudication and pricing based on the submitted documentation).
 

cdcpc

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I got it to work. No--my state was not listed. Anyone have suggestions for those of us whose states are not listed on the article?

I found this website earlier when I was researching, but coudn't find the article. I had to click on the "I accept" button and then the document came right up.

Here's the address for the document. I'm not sure if it will work, but it's worth a try:
https://www.noridianmedicare.com/shared/partb/bulletins/2007/237_may/Evaluation_and_Management_Service_Unlisted_Code_CPT_99499.htm

Thanks:)
 
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cdcpc

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I just noticed the link I posted showed up exactly the same as yours. I'm not very internet-saavy. Sorry!
 
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