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Question about hospital consults/follow-up visits

  1. #1
    St Louis West Missouri Chapter
    Default Question about hospital consults/follow-up visits
    Medical Coding Books
    I think I know the answer to this question but I need something in print. So far I have been unable to find documentation on this subject, so I need some enlightenment.
    One of our physicians did an inpatient hospital consult, but it was really an initial hospital visit since the patient has Medicare. Anyway, this patient was new to him, but his documentation did not meet the required criteria and therefore (as far as I know), the visit would have to be billed as a 99499 with the documentation to be sent out as requested.
    Someone in our office suggested that I bill the visit as a hospital follow-up visit (subsequent hospital care). It's my understanding that we cannot do this, since the patient had never been seen by this doctor or any other doctors in our group, previously. In fact, another doctor in our group saw the patient the following day in the hospital.
    I know a lot of things changed when Medicare stopped recognizing consultation codes, but as far as I know, the rules to bill follow-up (subsequent) hospital visits had not changed.
    So, is my only option to bill the visit with a 99499? I cannot crosswalk it to any other "new patient hospital" codes, from his documentation.
    Also, if anyone could point me in the direction of any websites, or anyplace that could further define/explain the rules of this kind of billing, I would really appreciate it.
    Thanks in advance!
    Last edited by punkyboo; 08-02-2010 at 09:36 AM.

  2. #2
    Columbia, MO
    This is a new patient consultation and the physician documentation does not meet the 99221 at the least? Then your choices are either the unlisted or the subsequent or request additional documentation from the physician.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    St Louis West Missouri Chapter
    Thanks Debra, you're quick

    So, I can bill a subsequent visit, even though the patient is new?

  4. #4
    North Carolina
    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 problem focused interval history” and “an expanded problem focused 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.

  5. #5
    St Louis West Missouri Chapter
    Thank you ladies, much appreciated

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