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Thread: Documentation for Initial hospital visits

  1. #1
    Join Date
    Apr 2007

    Question Documentation for Initial hospital visits

    AAPC: Back to School

    Hello all,
    I have a note that is not quite a detailed examination for an initial hospital visit. How should I bill that?


    Please see - see F

    It states to just bill the lowest level, but it also talks about seeing the patient 5 days prior and billed a level 5 office visit. My provider has not seen this patient since 4 months prior to this admission.

    Please help!!
    Kristen Richard, CPC

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Depends on your carrier

    This will depend on your carrier.

    WPS Medicare has specifically instructed us to use 99499 Unlisted E/M when documentation does not meet the minimum requirements for 99221.

    Other carriers want you to use the subsequent visit codes (99231-99233).

    Check with your carrier.

    Also ... since it's the exam that is at issue in your case ... did you audit using BOTH 1997 and 1995 guidelines. It may meet the standard with 1995.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Join Date
    Apr 2007


    WPS has backed off their direction for a 99499 in this case. When CMS changed the rules due to lack of consults, it changed the rules on this as well.

    You would use a subsequent care code based on current CMS guidelines.

    Laura, CPC, CPMA, CEMC

  4. #4
    Join Date
    Apr 2007
    North Carolina


    I agree with Laura. Although some carriers may refer to an unlisted code for those services that do not meet the requirements for 99251/99252, CMS now provides clear guidance for this scenario...

    How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?

    A. There is not an exact match of the code descriptors of the low level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.” Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

    Q. How will Medicare contractors handle claims for subsequent hospital care CPT codes that report the provider’s first E/M service furnished to a patient during the hospital stay?

    A. While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.


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