The CPT 2008 Professional Edition manual states that "for initial inpatient encounters by physicians other than the admitting physician, see inpatient consultation codes (CPT codes 99251-99255) or subsequent hospital care codes (CPT codes 99231-99233) as appropriate." The Medicare Claims Processing Manual also indicates that only one M.D. or D.O. may be the admitting physician, and only the admitting physician should use the initial hospital care codes. Do not submit the initial hospital care codes if you are not the admitting physician, even if you do a history and physical during your initial hospital encounter with the patient. The initial hospital care codes (CPT codes 99221-99223) should be used to report "the first hospital inpatient encounter with the patient by the admitting physician."
If you are not the admitting physician of record, you should bill the inpatient evaluation and management (E/M) CPT codes that describe your participation in the patient's care (i.e., subsequent hospital visit or inpatient consultation). The dates of service and whether the admitting physician actually bills for the admission are not relevant to the issue of whether the attending physician can bill for initial hospital care. The admitting physician can bill an initial hospital care code on the date the patient enters the facility or on another date as long as it represents "the first hospital inpatient encounter with the patient by the admitting physician." Of course, if the admitting physician does not do the work associated with the initial hospital care codes (i.e., the history, exam and medical decision making required by CPT), he or she should not bill for initial hospital care. In this case, the opportunity to bill for initial hospital care is lost.
Possible Reasons for Denials/Changes of Initial Hospital Care Services
1) Admitting vs. Other Physicians
Physicians use the initial hospital care codes (CPT codes 99221-99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician.
Contractors consider only one M.D. or D.O. to be the admitting physician and permit only the admitting physician to use the initial hospital care codes. Physicians that participate in the care of a patient but are not the admitting physician of record should bill the inpatient evaluation and management services codes that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient consultation).
2) Initial Hospital Care on the same day as an Emergency Room, Physician Office or Nursing Facility Visit
Contractors pay for an initial hospital care service or an initial inpatient consultation if a physician sees his/her patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.
3) Initial Hospital Care on Day Following Visit
Contractors pay both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission.
4) Initial Hospital Care and Discharge on Same Day
When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then initial hospital care (CPT codes 99221 – 99223) shall be reported by the physician. The hospital discharge day management service, CPT codes 99238 or 99239, shall not be reported for this scenario.
When a patient is admitted to inpatient initial hospital care and then discharged on a different calendar date, the physician shall report initial hospital care CPT codes 99221 – 99223 and a hospital discharge day management service, CPT code 99238 or 99239.
When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, observation or inpatient hospital care services (including admission and discharge services), CPT codes 99234 – 99236 shall be reported.
5) Initial Hospital Care Service: History and Physical That Is Less Than Comprehensive
When a physician performs a visit or consultation that meets the definition of a Level 5 office visit or consultation several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit or consultation that reflects the services furnished and also report the lowest level initial hospital care code (i.e., CPT code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code.
Common Medical Record Submission Errors
1) Unacceptable Signatures
Medicare requires the individual who provided services to be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend you include your applicable credentials, (e.g., P.A., D.O., or M.D.) The signature requirements recently changed and are applicable to every Medicare claim processed by Palmetto GBA on or after April 28, 2008 (for dates of service beginning with September 3, 2007).
2) Illegible handwriting
On review, illegible entries and non-standard abbreviations that are not easily understood cannot be given credit. Handwritten entries by a scribe, dictated notes and template entries signed by the provider are acceptable alternatives.
3) No Patient Name, Date of Service or an Acceptable Provider Signature in the Medical Record
Each medical record shall contain sufficient, accurate information to identify the patient and date that the service was provided. All pages of the medical record must be marked with the patient’s name and date of service.
The medical record must include the physician’s signature on all documentation. Medicare requires a legible identity for services provided/ordered. Palmetto GBA must clearly be able to tell who rendered the service and who wrote the notes. The Palmetto GBA Website includes specific examples of acceptable/unacceptable signatures.
References
- The Medicare Claims Processing Manual 100-04, Chapter 12 – Physician / Practitioner Billing, Section 30.6.9.1 Payment for Initial Hospital Care Services (CPT Codes 99221 - 99223) and Observation or Inpatient Care Services (Including Admission and Discharge Services) (CPT Codes 99234 – 99236), which can be found on the CMS Web site at www.cms.hhs.gov/manuals/iom/list.asp.
- E/M Documentation Guidelines, developed by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA): www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp.
- The Palmetto GBA E/M Help Center includes educational resource materials, and the Palmetto GBA E/M Score Sheets. The E/M Help Center is located under “Browse by Topic” on the Ohio, South Carolina and West Virginia home pages: Ohio: www.PalmettoGBA.com/boh, South Carolina: www.PalmettoGBA.com/bsc and West Virginia: www.PalmettoGBA.com/bwv.
- For Signature References and Exceptions, please refer to The Medicare Program Integrity Manual (PIM) 100-08 Chapter 3 – Verifying Potential Errors and Taking Corrective Actions, Section 3.4.1.1B. Change Request (CR) 5971 clarifies the instructions in the PIM. www.cms.hhs.gov/manuals/iom/list.asp.
- Read more about the CERT program on the CMS Web site: www.cms.hhs.gov/cert.