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Billing 99223 vs 99233

  1. Smile Billing 99223 vs 99233
    Medical Coding Books
    We has a billing consultant come in and he was telling us we should bill 99223 for all our inital hospital visits for Medicare. We were taugt that code is used by the admitting Doc only. We have been using 99233 even if it is the first time Dr has seen the pt in the hospital does anyone know for sure what the answer is Thanks Nancy

  2. #2
    North Carolina
    G. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission

    In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). Contractors consider only one M.D. or D.O. to be the principal physician of record (sometimes referred to as the admitting physician.) The principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. Only the principal physician of record shall append modifier “-AI”, Principal Physician of Record, in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.

    I do not agree that every initial, inpatient visit should be coded as 99223. You report the appropriate initial code that supports the documentation. As for the admitting MD, he reports the initial visit with AI modifier to indicate that he/she is the admitting MD. This is how Medicare differentiates between the admitting and another MD rendering service.
    Last edited by RebeccaWoodward*; 09-20-2011 at 11:37 AM.

  3. Default
    Thanks for your help to clear up this situation. I have one more question though. Other insurances do not follow this do they?

  4. #4
    To touch on the first question. If a doctor is asked to come in and "consult" and it fits the rules for billing a true consult, then yes you would bill a 99221-99223. However, if the doctor is "consulting" on a problem they will be managing or currently manage then you should bill a 99231-99233. This is how we do it at our clinic.

    To answer you second question, the only insurance companies that follow this, as far as I know, are Medicare and Medicaid insurances.

    Hope this helps!
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

  5. #5
    North Carolina
    1-If it is a consult, you crosswalk the code to the appropriate initial, inpatient (assuming this is an inpt scenario) hospital code (99221-99223); however, if documentation can't support 99221, you would need to crosswalk it with 99231/99232.

    2-If your physician is the admitting MD, report the initial, inpatient visit (supported by documentation) with the AI modifier. (again, assuming this is inpatient)

    3-If the admitting MD requests you to see the patient (not a consultation), report services from 99221-99223 as supported by documentation (as outlined in the MCR guidance above)

    4-All Subsequent visits are reported with 99231-99233.

    As for your 2nd question, CPT instructs differently. If unsure if your carrier follows MCR's guidelines, you would need to contact them directly.

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