Patient Care

Admit Documentation


 

In light of the recent elimination of consultation codes from the Medicare Physician Fee Schedule, physicians of all specialties are being asked to report initial hospital care services (99221-99223) for their first encounter with a patient.1 This leaves hospitalists with questions about the billing and financial implications of reporting admissions services.

Here’s a typical scenario: Dr. A admits a Medicare patient to the hospital from the ED for hyperglycemia and dehydration in the setting of uncontrolled diabetes. He performs and documents an initial hospital-care service on day one of the admission. On day two, another hospitalist, Dr. B, who works in the same HM group, sees the patient for the first time. What should each of the physicians report for their first encounter with the patient?

Each hospitalist should select the CPT code that best fits the service and their role in the case. Remember, only one physician is named “attending of record” or “admitting physician.”

When billing during the course of the hospitalization, consider all physicians of the same specialty in the same provider group as the “admitting physician/group.”

FAQ

Q: Should the attending physician or HM group of record append modifier “AI” to all services provided during the hospitalization?

Answer: As stated above, AI identifies the initial hospital-care service (i.e., admission service) performed by the attending of record. According to the CPT manual, all other physicians who perform an initial or subsequent evaluation will bill only the E/M code for the complexity level performed.5 There should be no financial implications if other claims erroneously include modifier AI on codes other than the initial hospital visit codes.

Furthermore, CMS has not required modifier AI reporting to involve a formal transfer of care. It stands to reason that the attending of record will not have to append modifier AI to their service, as this transfer service is reported as subsequent hospital care (99231-99233) and not as an initial hospital-care service (99221-99223).—CP

Admissions Service

On day one, Dr. A admits the patient. He performs and documents a comprehensive history, a comprehensive exam, and medical decision-making of high complexity. The documentation corresponds to the highest initial admission service, 99223. Given the recent Medicare billing changes, the attending of record is required to append modifier “AI” (principal physician of record) to the admission service (e.g., 99223-AI).

The purpose of this modifier is “to identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.”2 This modifier has no financial implications. It does not increase or decrease the payment associated with the reported visit level (i.e., 99223 is reimbursed at a national rate of approximately $190, with or without modifier AI).

Initial Encounter by Team Members

As previously stated, the elimination of consultation services requires physicians to report their initial hospital encounter with an initial hospital-care code (i.e., 99221-99223). However, Medicare states that “physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”3 This means followup services performed on days subsequent to a group member’s initial admission service must be reported with subsequent hospital-care codes (99231-99233). Therefore, in the scenario above, Dr. B is obligated to report the appropriate subsequent hospital-care code for his patient encounter on day two.

Incomplete Documentation

Initial hospital-care services (99221-99223) require the physician to obtain, perform, and document the necessary elements of history, physical exam, and medical decision-making in support of the code reported on the claim. There are occasions when the physician’s documentation does not support the lowest code (i.e., 99221). A reasonable approach is to report the service with an unlisted E&M code (99499). “Unlisted” codes do not have a payor-recognized code description or fee. When reporting an unlisted code, the biller must manually enter a charge description (e.g., expanded problem-focused admissions service) and a fee. A payor-prompted request for documentation is likely before payment is made.

Some payors have more specific references to the situation and allow for options. Two options exist for coding services that do not meet the work and/or medical necessity requirements of 99221-99223: report an unlisted E&M service (99499); or report a subsequent hospital care code (99231-99233) that appropriately reflects physician work and medical necessity for the service, and avoids mandatory medical record submission and manual medical review.4

In fact, Medicare Administrator Contractor TrailBlazer Health’s Web site (www.trailblazerhealth.com) offers guidance to physicians who are unsure if subsequent hospital care is an appropriate choice for this dilemma: “TrailBlazer recognizes provider reluctance to miscode initial hospital care as subsequent hospital care. However, doing so is preferable in that it allows Medicare to process and pay the claims much more efficiently. For those concerned about miscoding these services, please understand that TrailBlazer will not find fault with providers who choose this option when records appropriately demonstrate the work and medical necessity of the subsequent code chosen.”4 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is faculty for SHM’s inpatient coding course.

References

  1. CMS announces payment, policy changes for physicians services to Medicare beneficiaries in 2010. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/apps/media/ press/release.asp?Counter=3539&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Nov. 12, 2009.
  2. Revisions to Consultation Services Payment Policy. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/ MM6740.pdf. Accessed Jan. 16, 2010.
  3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2010.
  4. Update-evaluation and management services formerly coded as consultations. Trailblazer Health Enterprises Web site. Available at: www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1. Accessed Jan. 17, 2010.
  5. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2009;14-15.

Codes of the Month: Initial Hospital Care

99221: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:5

  • Detailed or comprehensive history;
  • Detailed or comprehensive examination; and
  • Medical decision-making that is straightforward or of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission is of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

99222: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:5

  • Comprehensive history;
  • Comprehensive examination; and
  • Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission is of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:5

  • Comprehensive history;
  • Comprehensive examination; and
  • Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission is of high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Note: These codes are used for new or established patients (e.g., a patient who has received face-to-face services from a physician or someone from the physician’s group within the past three years). The physician does not have to spend the associated “typical” visit time with the patient in order to report an initial hospital-care code. Time is only considered when more than 50% of the total visit time is spent counseling or coordinating patient care. See Section 30.6.1C, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf, for more information about reporting visit level based on time.—CP

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