cpt code 99221, 99222 - Hospital care Guide

procedure code and description

99221 - Initial hospital care - average fee payment - $100 - $120

When we can bill procedure code 99221

When a patient is admitted to inpatient hospital care for less than 8 hours on the same calendar date, the physician shall report Initial Hospital Care using a code from procedure  code range 99221 – 99223. The Hospital Discharge Day Management Service, procedure  code 99238 or 99239, shall not be reported for this scenario.

When a patient is admitted for inpatient hospital care and discharged on a different calendar date, the physician shall report Initial Hospital Care using a code from procedure  code range 99221 – 99223 and procedure  code 99238 or 99239 for a Hospital Discharge Day Management Service.

When a patient is admitted to inpatient hospital care for a minimum of 8 hours, but less than 24 hours and discharged on the same calendar date, the physician shall report the Observation or Inpatient Hospital Care Services (Including Admission and Discharge Service Same Day) using a code from procedure  code range 99234 – 99236, and no additional discharge service.

Physician documentation shall meet the evaluation and management (E/M) documentation requirements for history, examination and medical decision making. In addition, the physician shall identify he/she was physically present and that he personally performed the initial hospital care service. The physician shall personally document the admission and discharge notes and include the number of hours the patient remained in inpatient hospital care status.

Evaluation & management tips: Initial hospital care, new or established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:

1. History,
2. Examination, and
3. Medical decision-making.

When billing initial hospital care, all three key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.
CPT codes and requirements

99221 - 30 minutes (average)

• Detailed OR comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Detailed - Extended review of systems; Pertinent past, family and or social history
• Comprehensive - Complete review of systems; Complete past, family, and social history
• Detailed OR comprehensive examination. Documentation needed:
• Detailed - Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
• Comprehensive - General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)
• Medical decision making that is straightforward OR of low complexity. Documentation needed (two of three below must be met or exceeded):
• Straightforward - Minimal number of diagnoses or management options; None or minimal amount and/or complexity of data to be reviewed; Minimal risk of significant complications, morbidity and/or mortality
• Low complexity - Limited number of diagnoses or management options; Limited amount and/or complexity of data to be reviewed; Low risk of significant complications, morbidity and/or mortality


99222 - 50 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)
• Medical decision making that is moderate complexity. Documentation needed (two of three below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality



Can I submit a subsequent hospital visit if my documentation does not support one of the three levels of an initial hospital visit?

Answer:

Yes. If the minimal documentation requirements for the initial hospital visit (CPT codes 99221-99223) have not been met, the appropriate subsequent hospital visit (CPT codes 99231-99233) may be submitted.
Principal Physician of Record (Admitting Physician)
No. If the minimal documentation requirements are not met the principal physician of record (admitting physician) may submit the unlisted E/M CPT code 99499. Do not submit a subsequent hospital visit.

Note: Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment.



Can I submit a subsequent nursing facility CPT code if my documentation does not support one of the three levels of initial nursing facility services?

Answer:

Yes. If the minimal documentation requirements are not met for an initial nursing facility service (CPT codes 99304-99306), the appropriate subsequent nursing facility service (CPT codes 99307-99310) may be submitted.

Principal Physician of Record (Admitting Physician)
No. If the minimal documentation requirements are not met the principal physician of record (admitting physician) may submit the unlisted E/M CPT code 99499.  Do not submit a subsequent hospital visit.

Note: Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment.

Can a nurse practitioner perform the initial hospital visit?

Answer:
Yes, nurse practitioners can perform the initial hospital visit after enrolling for, and receiving, their own Medicare number. They must apply for an National Provider Identifier (NPI) and go through the Medicare credentialing process with Palmetto GBA, so they can order diagnostic tests. They can act as the assistant at surgery using HCPCS modifier AS, but they are excluded from billing as the surgeon on any major surgical procedure. They are excluded from some other specialty services, such as anesthesia.


Billing Guide and Policy: 

Effective January 1, 2010, procedure  consultation codes were no longer recognized for Medicare Part B payment. As explained in CR 6740, Transmittal 1875, Revisions to Consultation Services Payment Policy, issued on December 14, 2009, physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. CMS instructed providers billing under the PFS to use other applicable E/M codes to report the services that could be described by procedure  consultation codes. CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians where permitted) who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).

CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with procedure  consultation codes and for which the minimum key component work and/or medical necessity requirements for procedure  codes 99221 through 99223 are not documented. Providers may report procedure  code 99221 for an E/M service if the requirements for billing that code, which are greater than procedure  consultation codes 99251 and 99252, are met by the service furnished to the patient.

In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care procedure  codes (99231 and 99232) could potentially meet requirements to be reported for an E/M service that could be described by procedure  consultation code 99251 or99252. Contractors shall expect changes to physician billing practices accordingly. Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) 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 .



A. Hospital Visit and Critical Care on Same Day

When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (procedure  codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital
emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with procedure  Subsequent Hospital Care using a code from procedure  code range 99231 – 99233. Both Initial Hospital Care (procedure  codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians  of the same specialty from the same group practice.



C. 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, from procedure  code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, procedure  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 an Initial Hospital Care from procedure  code range 99221 – 99223 and a Hospital Discharge Day Management service, procedure  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), from procedure  code range 99234 – 99236, shall be reported.




F. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive

When a physician performs a visit that meets the definition of a Level 5 office visit 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 that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code.

Physicians who provide an initial visit to a patient during inpatient hospital care that meets the minimum key component work and/or medical necessity requirements shall report an initial hospital care code (99221-99223). The principal physician of record shall append modifier “-AI” (Principal Physician of Record) to the claim for the initial hospital care code. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.

Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with procedure  consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report procedure  code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

Subsequent hospital care procedure  codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by procedure  consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care procedure  code for services that were reported as procedure  consultation codes (99241 – 99255) prior to January 1, 2010, 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.

Reporting procedure  code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service.
Reporting procedure  code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these
circumstances to be unusual.


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.

Consultation code as admit code

Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.

Modifier “-AI,” defined as “Principal Physician of Record,” shall be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed. NOTE: The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes. It is not necessary to reject claims that include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes). Follow-up visits in the facility setting may be billed as subsequent hospital care visits and subsequent nursing facility care visits as is the current policy. In all cases, physicians shall bill the available code that most appropriately describes the level of the services provided.

Initial Hospital Care From Emergency Room

Contractors pay for an initial hospital care service if a physician sees a 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.

B. 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.

C. 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, from procedure  code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, procedure  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 an Initial Hospital Care from procedure  code range 99221 – 99223 and a Hospital Discharge Day Management service, procedure  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), from procedure  code range 99234 – 99236, shall be reported.

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