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E/M question on guidelines

  1. #1
    Location
    Jacksonville Florida
    Posts
    126
    Default E/M question on guidelines
    Medical Coding Books
    Good Morning everyone

    This scenario is for Medicare patients in an inpatient hospital setting:

    I have a physician that seems to think that if he sees a patient in the hospital in the last 3 years, that he can only bill for a subsequent visit 99231-99233. I know about the 3 year rule on a new/est patient in the office setting, never heard of this applying to a patient in an inpatient setting. I have been taught that if the patient is admitted for a new complication that we have not seen the patient for, and we are consulted by the admitted physician, it is billed with the 99221-99223 codes without the "AI" modifier. I have tried to explain to the physician that if the patient is established and its an admission for an issue that is known, then we would bill the 99231-99233. Am I understanding this right? I've tried to find documentation on Medicare's website about this kind of scenario and I'm having a hard time. If anyone can send me a link that may help so I can show my doctor the correct way to bill these that would be great.
    Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA

  2. #2
    Location
    Manhattan, NY
    Posts
    390
    Default
    Hope this is what you are looking for. https://www.cms.gov/mlnmattersarticl...ads/mm6740.pdf

  3. #3
    Default
    Quote Originally Posted by jlb102780 View Post
    Good Morning everyone

    This scenario is for Medicare patients in an inpatient hospital setting:

    I have a physician that seems to think that if he sees a patient in the hospital in the last 3 years, that he can only bill for a subsequent visit 99231-99233. I know about the 3 year rule on a new/est patient in the office setting, never heard of this applying to a patient in an inpatient setting. I have been taught that if the patient is admitted for a new complication that we have not seen the patient for, and we are consulted by the admitted physician, it is billed with the 99221-99223 codes without the "AI" modifier. I have tried to explain to the physician that if the patient is established and its an admission for an issue that is known, then we would bill the 99231-99233. Am I understanding this right? I've tried to find documentation on Medicare's website about this kind of scenario and I'm having a hard time. If anyone can send me a link that may help so I can show my doctor the correct way to bill these that would be great.
    New vs. Established Patient isn't the same as Initial vs. Subsequent Encounter...

    You can have an initial visit with an established patient - the "initial/Subsequent" designation refers to the encounter at that particular site of service, for that particular admission - not necessarily whether or not the provider's ever seen the patient before. It looks like you understand the guidelines, to me.

  4. #4
    Location
    Jacksonville Florida
    Posts
    126
    Default
    Thanks so much! That MRN article was actually what my doctors were given originally by our Admin office. They were reading the guidelines wrong thinking that the 3 year rule applied to hospital inpatient services. Thanks for the replies
    Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA

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