Inpatient Hospital Requirements - DRG and Per Diem concept

Inpatient services are generally reimbursed based on one of the following:

• DRG, or

• Per Diem


Outlined below are generally accepted billing guidelines. This is intended to be illustrative and is not an all-inclusive list.

• The Admission Date field should reflect the true admission date for inpatient claims.

• The Statement Covers Period should reflect the beginning and ending service dates for the period included on the bill.

• Day of Discharge or Death is not counted as a covered day, unless admitted and discharged/deceased on the same day.

• For institutional claims with Bill Type 11X, the number of Covered Days is required and must be reported using "Value Code" 80.

Specifically, the number of Covered Days is a manual calculation of the length of stay by counting from the admit date to the day before discharge. Count all days except the day of discharge to get the patient's length of stay.

• Submit separate bills for mother and baby for obstetric and neonatal services.

• Reimbursement for newborn hearing screenings is included as part of the inpatient stay associated with a birth. It is the hospital’s responsibility to establish payment arrangements with physicians for the technical portions of this service if the necessary equipment is not available at the hospital.

• Submit one bill to Florida Blue upon member discharge, transfer or death.

• All charges related to a hospital admission, including any charges for outpatient procedures, surgical or non-surgical (including observation), incurred within 72 hours of an admission (unless otherwise specified in your contract) must be itemized on the UB-04 bill for the admission and will be included in the inpatient allowance.

• All relevant services that are part of an admission, including transfers within the hospital (e.g., from a medical surgical unit to a psychiatric unit or acute rehabilitation unit), should be included on one bill.


Exception: If separate contracts exist for a hospital’s DPU(s) and/or NPIs associated with any specialty unit or other hospital owned entity.


• Include charges for preoperative testing related to surgery on the same bill as the surgery, whether or not the testing was provided on the date of surgery. For an inpatient claim, the From Date and Admission Date will be different, as the Admission Date will be the date the patient was admitted to the hospital while the From Date reflects the date pre-operative services were performed.

• No interim or split bills.

• Bill physician/professional fees (0960-0989) on a CMS-1500 form.

• For hospitals that have a per diem contract, the revenue code that applies to the specific per diem room and board rate or medical condition should be used (e.g., maternity/OB admissions should be billed with the applicable room and board revenue code ending with a 2).

• Florida Blue can only accept claims with up to 12 diagnosis codes and up to 6 procedure codes.

• Diagnosis codes impacting the DRG assignment should be in the first through 12 diagnosis code position.

• Report only the ICD diagnoses codes corresponding to conditions that affect the treatment received and/or length of stay.

• If surgery is performed and a charge is made for the operating room, recovery room, or special procedure room, an ICD procedure code must be entered on all inpatient claims.

• POA Indicators are required for all primary and secondary diagnosis codes billed on inpatient acute care hospital claims.

• A private room is only covered if it is medically necessary or no semi-private room is available. The difference between the private and semi-private room rate is a non-covered amount and the patient's liability. For information on billing and reporting inpatient room and board refer to Coding a Facility Claim.

• Care associated with HACs, as defined by CMS, is taken into consideration when the DRG is assigned. Those coded with an “N” or a “U” indicator will be excluded from the DRG grouping.

• Beginning August 1, 2015 for claim submissions where the member is admitted to the hospital through the emergency room, non-participating BlueSelect hospitals and facilities should submit two separate bills (one for emergency services and another for inpatient services) so that Florida Blue can apply the in-network benefits to the emergency room services.


Note: The “U” indicator is subject to specific guidelines with regard to the patient status code before it is excluded from the DRG grouping process.

Services Included in the DRG or Per Diem Payment

Examples of items that should not be submitted as separate charges since they are included in the DRG or per diem payment, as applicable:

• Non-physician professional services, including all non-physician professional personnel time.

• Supplies routinely provided with a service or procedure (e.g., X-ray film, lab collection devices).

• Re-stock charges, processing fees and other direct administrative expenses. Pharmacy compounding equipment, supplies and fees (e.g., Laminar flow hoods).

• Any indirect expenses, including but not limited to housekeeping, dietary, plant and equipment maintenance, utilities and insurance.

Present of Admission (POA) Indicator list on UB 04

The table below outlines the payment implications for each of the different POA Indicator reporting options.


POA Indicator Options and Definitions Code  Description


Y    Diagnosis was present at time of inpatient admission. Florida Blue will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator

N   Diagnosis was not present at time of inpatient admission. Florida Blue will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.

U  Documentation insufficient to determine if the condition was present at the time of inpatient admission. Florida Blue will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.

W  Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Florida Blue will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.

1 Unreported/Not used. Exempt from POA reporting. This code was the equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. For 5010 reporting, the 1 is no longer valid because POAs are no longer reported in a separate string.


Present On Admission (POA) Indicator

Note: This article was updated on June 5, 2013, to reflect current Web addresses. This article was previously revised on September 11, 2007, to clarify the timeframes for reporting the POA indicators. All other information remains unchanged.

Background

Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses that are present on admission (POA) of patients effective for discharges on or after October 1, 2007. By October 1, 2007, the Centers for Medicare & Medicaid Services (CMS) will have selected at least 2 high cost or high volume (or both) diagnosis codes that:

• Represent conditions (including certain hospital acquired infections) that could reasonably have been prevented through the application of evidence-based guidelines; and

• When present on a claim along with other (secondary) diagnoses, have a DRG assignment with a higher payment weight.

Then, for acute care inpatient PPS discharges on or after October 1, 2008, while the presence of these diagnosis codes on claims could allow the assignment of a higher paying DRG, when they are present at the time of discharge, but not at the time of admission, the DRG that must be assigned to the claim will be the one that does not result in the higher payment.

Beginning for discharges on or after October 1, 2007, hospitals should begin reporting the POA code for acute care inpatient PPS discharges. There is one exception, i.e., claims submitted via direct data entry (DDE) should not report the POA codes until January 1, 2008, as the DDE screens will not be able to accommodate the codes until that date.

Between October 1, 2007, and December 31, 2007, CMS will collect the information on the hospital claim, but does not intend to provide any remittance or other information to hospitals if the information is not submitted correctly for each diagnosis on the claim. Hospitals that fail to provide the POA code for discharges on or after January 1, 2008 will receive a remittance advice remark code informing  them that they failed to report a valid POA code. However, beginning with discharges on or after April 1, 2008, Medicare will return claims to the hospital if  the POA  code is not reported and the hospital will have to supply the correct POA code and resubmit the claim. In order to be able to group these diagnoses into the proper  DRG, CMS needs to capture a Present On Admission (POA) indicator for all claims involving inpatient admissions to general acute care hospitals. CR 5499, from which  this article is taken, announces this requirement and provides your fiscal intermediaries (FI) and A/B MACs with the coding and editing requirements, and software  modifications needed to successfully implement this indicator.

Note: Adjustments to the relative weight that occur because of this action are not budget neutral. Specifically, aggregate payments for discharges in a fiscal year could be changed as a result of these adjustments.

These POA guidelines are not intended to replace any found in the ICD-9-CM Official Guidelines for Coding and Reporting, nor are they intended to provide guidance on when a condition should be coded. Rather, you should use them in conjunction with the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each “principal” diagnosis and “other” diagnoses codes reported on claim forms (UB-04 and 837 Institutional). Information regarding the UB-04 Data Specifications may be found at http://www.nubc.org/become.html on the Internet.

Note: Critical access hospitals, Maryland waiver hospitals, long term care hospitals, cancer hospitals, and children’s inpatient facilities are exempt from this requirement.

The following information, from the UB-04 Data Specifications Manual, is provided to help you understand how and when to code POA indicators:

1. General Reporting Requirements

• Pertain to all claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.

• Present on admission is defined as present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

• POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.

• Issues related to inconsistent, missing, conflicting, or unclear documentation must still be resolved by the provider.

• If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.

• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”

2. Reporting Options and Definitions

• Y - Yes (present at the time of inpatient admission)

• N – No (not present at the time of inpatient admission)

• U - Unknown (documentation is insufficient to determine if condition is present at time of inpatient admission)

• W – Clinically undetermined (provider is unable to clinically determine whether condition was present at time of inpatient admission or not)

• 1 -- Unreported/Not used – Exempt from POA reporting (This code is the equivalent of a blank on the UB-04, but blanks are not desirable when submitting data via the 4010A1.

The POA data element on your electronic claims must contain the letters “POA”, followed by a single POA indicator for every diagnosis that you report. The POA indicator for the principal diagnosis should be the first indicator after “POA,” and (when applicable) the POA indicators for secondary diagnoses would follow. The last POA indicator must be followed by the letter “Z” to indicate the end of the data element (or FIs and A/B MACs will allow the letter “X” which CMS may use to identify special data processing situations in the future).

Note that on paper claims the POA is the eighth digit of the Principal Diagnosis field (FL 67), and the eighth digit of each of the secondary diagnosis fields (FL 67 A-Q); and on claims submitted electronically via 837, 4010 format, you must use segment K3 in the 2300 loop, data element K301. Below is an example of what this coding should look like on an electronic claim:

If segment K3 read as follows: “POAYNUW1YZ,” it would represent the POA indicators for a claim with 1 principal and 5 secondary diagnoses. The principal diagnosis was POA (Y), the first secondary diagnosis was not POA (N), it was unknown if the second secondary diagnosis was POA (U), it is clinically undetermined if the third secondary diagnosis was POA (W), the fourth secondary diagnosis was exempt from reporting for POA (1), and the fifth secondary diagnosis was POA (Y).

As of January 1, 2008, all direct data entry (DDE) screens will allow for the entry of POA data and POA data will also be included with any secondary claims sent by Medicare for coordination of benefits purposes. See the complete instructions in the UB-04 Data Specifications Manual for more specific instructions and examples.

Note: CMS, in consultation with the Centers for Disease Control and Prevention and other appropriate entities, may revise the list of selected diagnose from time to time, but there will always be at least two conditions selected for discharges occurring during any fiscal year. Further, this list of diagnosis codes and DRGs is not subject to judicial review.

Finally, you should keep in mind that achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures requires a joint effort between the healthcare provider and the coder. Medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not; and the importance of consistent, complete documentation in the medical record cannot be overemphasized.

NOTE: You, your billing office, third party billing agents and anyone else involved in the transmission of this data must insure that any resequencing  of diagnoses codes prior to their transmission to CMS, also includes aresequencing of the POA indicators.


UB-04 Desk Reference for Hospitals


ThesevaluesarevalidforpaperclaimsubmissionontheUB-04ClaimFormonly.


Type of Bill Codes (Form Locator 4)

INPATIENT ONLY: First Digit

1 Type of Facility – Hospital Second Digit
1 Bill Classification – Inpatient

Third Digit
0 Non Payment/Zero Claim
1 Admit through Discharge Claim
2 Interim – First Claim
7 Replacement of Prior Claim
8 Void/Cancel of Prior Claim

OUTPATIENT ONLY:

First Digit
1 Type of Facility – Hospital Second Digit
3 Bill Classification – Outpatient
4 Bill Classification – Hospital Special Treatment Room

Third Digit
0 Nonpayment/Zero Claim
1 Admit through Discharge Claim
7 Replacement of Prior Claim
8 Void/Cancel of Prior Claim

Admission Type (Form Locator 14)
1 Emergency Admission
2 Urgent Admission
3 Elective Admission
4 Newborn Admission
5 Trauma Admission (Emergency Admission)

Condition Codes (Form Locators 18–28)
2 Condition is Employment Related
3 Patient is Covered by Insurance Not Reflected Here
05 Lien Has Been Filed
44 Outpatient Observation Only
60 Day Outlier
77 Provider accepts or is obligated/required to a contractual agreement or law to accept payment by primary payer as payment in full

A1 EPSDT
A4 Family Planning Outpatient
AA Abortion Consent (MA 3) – Rape
AB Abortion Consent (MA 3) – Incest
AD Abortion Consent (MA 3) – Danger to Life
AI Sterilization Patient Consent Form (MA 31)
X2 Medicare EOMB on File
B3 Pregnancy
X3 Hysterectomy Acknowledgment Form (MA 30)
X4 Medicare Denial on File
X5 Third Party Payment on File
X6 Restricted Recipient Referral Form
X7 Medical Documentation for Hysterectomy
Y0 Newborn Eligibility
Y3 Copay Not Collected
Y6 Third Party Denial on File

Patient Status Codes (Form Locator 17)
1 Discharge to home or self-care – Routine Discharge
2 Discharged/transferred to another hospital for inpatient care
3 Discharged/transferred to a skilled nursing facility
04 Discharged/transferred to an intermediate care facility
05 Discharged/transferred to another type of institution for inpatient care
07 Left against medical advice or discontinued care
20 Expired
30 Still a patient

Occurrence Codes (Form Locators 31–34)
1 Auto Accident
2 No Fault Accident
3 Accident/Tort Liability
4 Accident/Employment Related
5 Other Accident
6 Crime Victim
24 Date Insurance Denied
25 Date Benefits Terminated By Primary Payer
A3 Benefits Exhausted
B3 Benefits Exhausted
C3 Benefits Exhausted
DR Disaster Related Occurrence Span Codes (Form Locator 35–36)
71 Prior Stay Dates
74 Non-covered Level of Care/Leave of Absence (JCAHO RTF only)
MR Disaster Related

What is Present on Admission Indicator Reporting ?

A Present on Admission (POA) Indicator is used to identify whether a primary or secondary condition was present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission.

For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions known as, Hospital Acquired Conditions (HACs), are present at the time of admission. The case will be reimbursed as though the secondary diagnosis were not present. Critical Access Hospitals (CAHs), Long-term Care Hospitals (LTCHs), Cancer Hospitals, Children's Inpatient Facilities, Inpatient Psychiatric Hospitals, Inpatient Rehabilitation Facilities, and Veterans Administration/Department of Defense Hospitals are exempt from this payment provision.


The Florida Blue Present on Admission (POA) Indicator requirement applies to both Inpatient Prospective Payment Systems (IPPS) and Non-IPPS Hospitals. A POA indicator should be submitted with all primary and secondary diagnoses codes, regardless of whether the condition is considered a Hospital Acquired Condition (HAC) or not.

If an indicator of “Y” or “W” is submitted with a HAC condition, the major complicating condition or complicating condition (MCC/CC) is included in DRG grouping logic. HAC conditions submitted with an “N” or a “U” will be excluded from DRG grouping impacts. The “U” indicator is subject to specific guidelines with regard to the patient status code before it is excluded from the DRG grouping
process.

Per Diem agreement and allowed amount calculation

Per Diem

Per Diem is a per day negotiated rate which represents an allowance that includes all services for that day.

Per Diem agreements reimburse based on the admission date of the member.

The following terminology is used when referring to per diem contracts:

• Inliers- Inpatient cases reimbursed based on room and board per diem rates

• Outliers- Inpatient cases reimbursed as a DRG carve-out or based on catastrophic reimbursement.


Per Diem Hierarchy for a Standard Base Agreement

Each inpatient case in a per diem contract is evaluated using the following payment hierarchy:

• Implant Carve-out - Typically reimbursed in addition to inliers and outliers

• Catastrophic - Outlier

• DRG Carve-outs as case rate with additional day per diem - Outlier

• Per Diem Rates - Inlier

Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step.


Calculating the Inpatient Allowed Amount

Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied. Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.


Per Diem Examples

Per Diem payment rate is based on room and board revenue codes (e.g., med/surg, ICU, psychiatric) ranging from 110-219. The following examples illustrate the per diem methods for determining payment for inpatient admissions. Per Diem Examples

DRG Hierarchy and calculation of allowed amount

DRG Hierarchy for a Standard Base Agreement


Each inpatient case for a DRG contract is evaluated using the following payment hierarchy:

• Low Stay Outlier

• High Charge/High Stay Outlier

• DRG Value Inlier

Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step. For example, if a case meets the qualification as a low stay case and a high charge case, it will be reimbursed based on the low stay allowance.

Note: The hierarchy for a hospital that provides tertiary services is different from the hierarchy list above.

Calculating the Inpatient Allowed Amount

Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied.

Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.

DRG Examples

The following examples illustrate the various methods for determining the allowed amount for inpatient admissions.


Use the following “case” for the calculations:

• DRG = DRG 202 Bronchitis and Asthma, with complication or major complication

• Conversion Price = $3,000

• Low (Length of Stay) Trim Point = 2 days*

• High (Length of Stay) Trim Point = 12 days*

• Contracted Negotiated Low Stay Per Diem = $750

• Contracted Negotiated High Stay Per Diem = $800

• Relative Weight = 0.8446

• DRG Value = $2,534 (Conversion Price x Relative Weight)

*Trim point is a numerical value that represents the minimum (in the case of the low trim point) and the maximum (in the case of the high trim point) number of days for which payment will be made at the DRG value for hospital services. Length of Stay Examples

Billing Guide for partial hospitalization

Partial Hospitalization

• Submit partial hospitalization services with the following revenue codes:

• 0912, 0913 or 0915

o If a separate contract for the hospital and psych DPU are in effect, submit partial hospitalization services and inpatient services on separate UB-04 claim forms.

• Florida Blue considers partial hospitalization to be an outpatient service.

• Partial hospitalization for psychiatric or substance abuse admissions is calculated as follows:

o Partial Days (including beginning and ending dates) x Per Diem.

DRG

DRGs are statistically meaningful medical groupings used for the purpose of categorization and reimbursement of hospital services.
• DRGs allow for more uniform billing based upon the member’s diagnosis and procedures, age, sex, and discharge status.

• Reimbursement for DRG cases is based on discharge date.

• Exception: A newly established participating provider, under a DRG contract, will have the first year of claims reimbursed based on the admission date of the inpatient claim.

• Deaths and transfers are reimbursed based on the assigned DRG and payment hierarchy logic. There are no special reimbursement arrangements applicable to deaths and transfers.

• A list of DRGs, along with length of stay trim points and relative weights, is contained in your hospital’s Agreement.


Outlier Cases

Outlier cases are exceptions to typical inpatient DRG cases. Refer to your Agreement for which outlier method applies.
There are three types of outlier cases but not limited to:

• Low length of stay outlier - Low Length is a case in which the member stays in the hospital fewer days than the low length of stay trim point.

• High length of stay outlier - High Length is a case in which the member stays in the hospital a greater number of days than the high length of stay trim point.

• High charge outlier- High charge is a case in which total covered charges exceed the high charge threshold.

CPT codes 99231 ,99232 and 99233 - Billing Example

99231 : Inpatient hospital visits: Initial and subsequent

subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key components: A problem focused interval history; A problem focused examination; 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 patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.

99232 : Inpatient hospital visits: Initial and subsequent

subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key components: An expanded problem focused interval history; An expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.

99233 : Inpatient hospital visits: Initial and subsequent

subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

CPT codes 99231-99233 are used to describe subsequent hospital care. These codes require documentation of the interval history at either problem focused, expanded problem focused, or detailed levels. The examination requires the same levels of documentation. The Medical decision making documentation must support straightforward, low, moderate, or high complexity. The nature of the presenting problem usually determines the levels of history and physical exam required.

1. CPT code 99231 usually requires documentation to support that the patient is stable, recovering, or improving.

2. CPT code 99232 usually requires documentation to support that the patient is responding inadequately to therapy or has developed a minor complication. Such minor complications might include careful monitoring of co-morbid conditions requiring continuous active management

3. CPT code 99233 usually requires documentation to support that the patient is unstable or has a significant new problem or complication.


Reporting Initial Hospital Care Codes

CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with CPT consultation codes, for which the minimum key component work and/or medical necessity requirements for CPT codes 99221 through 99223 are not documented.

** Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT 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 CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

** In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

** Subsequent hospital care CPT 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 CPT 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 CPT code for services that were reported as CPT 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 CPT 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 CPT 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.

Medicare contractors have been advised to expect changes to physician billing practices accordingly. Contractors will not find fault with providers who report subsequent hospital care codes (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) .


An important step in strengthening the links in your processes is to coordinate with other physicians, qualified health care professionals, and/or agencies. This will help ensure the counseling and/or care provided is consistent with the nature of the problems and the family’s needs. Be certain to review the record with these questions in mind:

1.Is the history problem focused, expanded problem focused or a detailed interval history ?

Remember that an interval history is one that documents an update on the patient from the last encounter.

2.Is the exam a focused exam, which is CPT code 99231; an expanded problem focused exam, code 99232; or a detailed exam, code 99233 ?

3.Is the medical decision making straight forward or low complexity, code 99231; moderate complexity, code 99232; or high complexity, which would be code 99233 ?

4. How much time did the physician spend at the patient’s bedside ?  Time is a factor that indicates the extent of the illness.


This will guide you in selecting the correct CPT code. Some other helpful tips to decrease denials include:

** Submit records within the 30-day time frame when Additional Documentation letters are received.

** Review medical documentation prior to submission for correct patient name and date of service.

** Verify that the provider’s signature is legible, or that there a signature log on file with Palmetto GBA.

** Verify that the complete date of service is legibly noted on all documentation.

Evaluation & management tips: Subsequent hospital care

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 subsequent hospital care, two of the 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

99231 - 15 minutes (average)

• Problem focused interval history.
• Chief complaint
• Brief history of present illness
• Problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system
• 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

99232 - 25 minutes (average)

• Expanded problem focused interval history.
• Chief complaint
• Brief history of present illness
• Problem pertinent review of systems
• Expanded problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system and any other symptomatic or related body area(s)or 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


99233 - 35 minutes (average)

• Detailed interval history.
• Chief complaint
• Extended history of present illness
• Extended review of systems
• Pertinent past, family and/or social history
• Detailed examination. Documentation needed:
• 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)
• Medical decision making that is of high complexity. Documentation needed (two of three below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality



Clinical Example:

Coding of the visits during a six-day hospitalization of an eighty year old patient with a presumptive diagnosis of pneumococcal pneumonia and low oxygen saturation.

First day after the day of admission: The patient continues tachypnic with low oxygen saturation, and febrile. The patient is receiving oxygen and broad-spectrum antibiotics awaiting cultures results. At present there is an inadequate response and condition would appear to support the levels of history and Physical exam required for CPT
code 99232.

Second day after the day of admission: Less tachypnea, still febrile, still receiving oxygen and broad spectrum –antibiotics. Culture results isolate no specific pathogen and current antibiotics are continued. A continued inadequate response would appear to support the levels of history and Physical exam required for CPT code 99232.

Third day after day of admission: Patient is afebrile, room air oxygen saturation is good. Patient is obviously improved. Current antibiotics continued intravenously for one more day. The patient is recovering and improving. Condition would appear to support the levels of history and Physical exam required for CPT code 99231.

Fourth day after the day of admission: Afebrile with good room air oxygen saturation. IV antibiotics are discontinued and patient started on oral antibiotics. The patient is recovering and improving. Condition would appear to support the levels of history and Physical exam required for CPT code 99231.

Fifth day after day of admission: Patient is discharged and the appropriate discharge code is billed.


Admission Visit Daily Visit Consultation

Time (min) Code Time (min) Code Time (min) Code

30 99221 15 99231 20 99251 50 99222 25 99232 40 99252 70 99223 35 99233 55 99253  80 99254  110 99255


In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially meet requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. 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.



Subsequent hospital care CPT 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 CPT 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 CPT code for services that were reported as CPT 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.

Chief Complaint:

The Chief Complaint is a concise statement from the patient describing:

• The symptom • Problem • Condition • Diagnosis • Physician recommended return, or other factor that is the reason for the encounter

Review of Systems: 

An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. For purpose of Review of Systems the following systems are recognized: • Constitutional (i.e., fever, weight loss) • Eyes • Ears, Nose, Mouth Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurologic • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic


Billing and Coding Guidelines.


Palmetto GBA focused on the Subsequent Hospital Care procedure range of 99231 through 99233.

When any level of subsequent hospital care is under review, the medical record should include results of diagnostic studies and changes to the patient’s status since the last assessment. Changes include history, physical condition and response to management.

An important step in strengthening the links in your processes is to coordinate with other physicians, qualified health care professionals, and/or agencies. This will help ensure the counseling and/or care provided is consistent with the nature of the problems and the family’s needs. Be certain to review the record with these questions in mind:

1. Is the history problem focused, expanded problem focused or a detailed interval history? Remember that an interval history is one that documents an update on the patient from the last encounter.

2. Is the exam a focused exam, which is CPT code 99231; an expanded problem focused exam, code 99232; or a detailed exam, code 99233?

3. Is the medical decision making straight forward or low complexity, code 99231; moderate complexity, code 99232; or high complexity, which would be code 99233?

4. How much time did the physician spend at the patient’s bedside? Time is a factor that  indicates the extent of the illness. This will guide you in selecting the correct CPT code.

The use of telehealth is limited in two ways: 

1. Subsequent hospital care services, with the limitation of one telehealth visit every 3 days (Common Procedural Terminology (CPT) codes 99231, 99232, and 99233); and 

2. Subsequent nursing facility care services, with the limitation of one telehealth visit every 30 days (CPT codes 99307, 99308, 99309, and 99310).

The Medicare physician fee schedule payment for surgical procedures includes all the services and visits that are part of the global surgery payment including when such surgical procedures may be fragmented. Subsequent Hospital Care visits (CPT codes 99231 – 99233) are not separately payable when included in the global surgery payment. The Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service with the patient and his/her attending physician. Physicians shall use the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from CPT code range 99234 – 99236 for a hospital admission and discharge occurring on the same calendar date and when specific Medicare criteria, identified in §30.6.9.1, are met. The American Medical Association Current Procedural Terminology (CPT) codes 99238 and 99239 shall be paid only when they are performed face-to-face with the patient. Other physicians who manage the patient’s care (concurrent care) in addition to an attending physician, and who are not acting on behalf of the attending physician shall use the Subsequent Hospital Care codes from CPT code range CPT 99231 – 99233 for a final visit with the patient. Medicare includes payment for general paperwork through the pre-and post-service work of E/M services. The physician who personally performs a patient pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service using CPT code 99238 or 99239. The date of death pronouncement shall reflect the calendar date of actual death pronouncement even if the paperwork is delayed to a subsequent calendar date.

Definition - Hospital , hospital admission, Inpatient hospital expense

Hospital means a short-term acute care facility which:

1. Is duly licensed as a Hospital by the state in which it is located and meets the standards established for such licensing, and is either accredited by the Joint Commission on Accreditation of Healthcare Organizations or is certified as a Hospital provider under Medicare;

2. Is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of Physicians or Behavioral Health Practitioners for compensation from its patients;

3. Has organized departments of medicine and major surgery, either on its premises or in facilities available to the Hospital on a contractual prearranged basis, and maintains clinical records on all patients;

4. Provides 24-hour nursing services by or under the supervision of a Registered Nurse;

5. Has in effect a Hospital Utilization Review Plan; and

6. Is not, other than incidentally, a Skilled Nursing Facility, nursing home, Custodial Care home, health resort, spa or sanitarium, place for rest, place for the aged, place for the treatment of Chemical Dependency, Hospice, or place for the provision of rehabilitative care.


Hospital Admission means the period between the time of a Participant's entry into a Hospital or a Chemical Dependency Treatment Center as a Bed patient and the time of discontinuance of bed-patient care or discharge by the admitting Physician, Behavioral Health Practitioner or Professional Other Provider, whichever first occurs. The day of entry, but not the day of discharge or departure, shall be considered in determining the length of a Hospital Admission. If a Participant is admitted to and discharged from a Hospital within a 24-hour period but is confined as a Bed patient in a bed accommodation during the period of time he is confined in the Hospital, the admission shall be considered a Hospital Admission by BCBSTX.


Inpatient Hospital Expense means the Allowable Amount incurred for the Medically Necessary items of service or supply listed below for the care of a Participant, provided that such items are:

1. Furnished at the direction or prescription of a Physician, Behavioral Health Practitioner or Professional Other Provider; and

2. Provided by a Hospital or a Chemical Dependency Treatment Center; and

3. Furnished to and used by the Participant during an inpatient Hospital Admission.

An expense shall be deemed to have been incurred on the date of provision of the service for which the charge is made.

Inpatient Hospital Expense shall include:

1. Room accommodation charges. If the Participant is in a private room, the amount of the room charge in excess of the Hospital's average semiprivate room charge is not an Eligible Expense.

2. All other usual Hospital services, including drugs and medications, which are Medically Necessary and consistent with the condition of the Participant. Personal items are not an Eligible Expense.

Medically Necessary Mental Health Care or treatment of Serious Mental Illness or treatment of Serious Mental Illness in a Psychiatric Day Treatment Facility, a Crisis Stabilization Unit or Facility, or a Residential Treatment Center for Children and Adolescents, in lieu of hospitalization, shall be Inpatient Hospital Expense.

Late Enrollee means any Employee or Dependent eligible for enrollment who requests enrollment in an Employer's Health Benefit Plan (1) after the expiration of the initial enrollment period established under the terms of the first plan for which that Participant was eligible through the Employer, (2) after the expiration of an Open Enrollment Period, or (3) after the expiration of a special enrollment period.

Medicare Review on CPT 99232 AND 99233

The top services for First Coast Service Options Inc. (First Coast) with payment errors identified by Part  B comprehensive error rate testing (CERT) continue to be evaluation and management services. First Coast conducted a data analysis for Current Procedural Terminology® (CPT®) codes 99232 and 99233 (subsequent hospital care). The data indicates specialties internal medicine and cardiology are the primary contributors to the CERT error rate for subsequent hospital care services. Documentation requirements  the American Medical Association (AMA) CPT® manual defines code 99232 as  follows: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

*** An expanded problem focused interval history ;

*** An expanded problem focused examination;

*** Medical decision making of moderate complexity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit.

The AMA CPT® manual defines code 99233 as follows: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of
these three key components:

*** A detailed interval history ;

*** A detailed examination;

*** Medical decision making of high complexity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs. Usually, the patient is unstable or has developed a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit. First Coast and the Centers for Medicare & Medicaid Service (CMS) offer multiple resources addressing the documentation guidelines for E/M service levels at:

*** First Coast’s Evaluation and Management (E/M) services page, offering links to tools, FAQs, online learning, and additional resources.

*** CMS Internet-only manual (IOM) guidelines addressing multiple types and settings pertaining to E/M services.


First Coast actions

In response to the high percentage of error rates and the continual risks of improper payments associated with subsequent hospital care billed by internal medicine and cardiology specialists, First Coast will be implementing a prepayment medical review audit for CPT® codes 99232 and 99233 billed by cardiology; and CPT® codes 99232 billed by internal medicine specialty. The new audit will be based on a threshold of claims submitted for payment  by cardiology and internal medicine specialties in an effort to reduce the error rates for these hospital services. The audit will be implemented for claims processed on or after March 15, 2016.


Readmission within 15 days to the Same Hospital (Unrelated Readmission)

If a beneficiary is readmitted to the same hospital within 15 days for a condition(s) unrelated to the previous admission (e.g., gall bladder removal, injuries due to a car accident), Medicaid considers the case a new admission for payment purposes.

** The provider must submit two separate claims to assure appropriate processing.

** A claim for the first admission must be submitted and paid prior to submission of the readmission claim.

** When completing the second (readmission) claim, the hospital must indicate the PACER number in the treatment authorization field and Occurrence Span Code 71 with "from" and "through" dates from the previous admission.

Readmission within 15 days to the Same Hospital (Related Admission)

If a beneficiary is readmitted to the same hospital within 15 days for a related (required as a consequence of the original admission) condition, Medicaid considers the admission and the related readmission as one episode for payment purposes. The
related admissions must be combined on a single claim. No PACER number is issued for continuation of care.

** Revenue code 0180 is used for the days the beneficiary was not in the hospital.

** Enter the number of leave days in the service units field.

** Leave the rate and total charges blank.

** Include the leave day units in the total units field.

** Report Occurrence Span Code 74 with "from" and "through" dates of the leave of absence.

** If the original admission has been submitted and paid, a replacement claim must be submitted that contains the combined services for the original admission and the readmission.


Readmission within 15 days to a Different Hospital

Enter the PACER number in the treatment authorization field and Occurrence Span Code 71 with "from" and "through" dates from the previous admission.

Transfers Authorization for a transfer is granted only if the transfer is medically necessary and the care/treatment is not available at the transferring hospital. Transfer for convenience is not considered. Authorization should be obtained by the next business day for emergent/urgent transfers.

** The receiving hospital enters the PACER number of the approved transfer in the treatment authorization field.

** Submission of documentation with the claim is not required when billing transfers.

Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?


A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.

When a beneficiary elects hospice during an inpatient stay:

• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election


When a patient revokes hospice during an inpatient stay:

• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

Consultation Services versus hospital care codes

 Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part Bpayment. 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.

In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

Contractors shall not find fault 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. Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M service that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service. Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual. T he 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. 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.

In the CAH setting, those CAHs that use method II shall bill the appropriate new or established visit code for those physician and non-physician practitioners who have reassigned their billing rights, depending on the relationship status between the physician and patient.

In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall use the CPT codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. All physicians and qualified nonphysician practitioners shall follow the E/M documentation guidelines for all E/M services. These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer


SERVICES INCLUDED IN THE INPATIENT PAYMENT

The following services are included in the inpatient payment:

* All routine services (e.g., room and board, nursing).

* All diagnostic/ancillary services (e.g., radiology, pharmacy, therapists, supplies, pathology).

* While a patient is in the inpatient setting, the facility charges for any services performed by persons or entities other than the patient's hospital (e.g., an independent lab, a second hospital where no transfer occurs) are covered in the payment to the patient's hospital and must not be billed separately. All charges must be included on the inpatient claim of the patient's hospital.

Any payments due to the second party are the responsibility of the patient's hospital.

* All pathology services that are performed by the pathologist but do not directly relate to the specific patient's care.

* All emergency room services provided by the hospital that result in an inpatient admission to that hospital. All charges must be included on the inpatient claim.

* An orthosis or prosthesis that is required for inpatient treatment, a surgical postoperative procedure or as a routine service of the hospital should be included as a supply on the inpatient claim and is reimbursed under the appropriate DRG.
Examples of items that are included in the inpatient payment are:

* Pacemakers

* Hip replacements

* Made-to-measure braces for compression fractures

* Compression stockings (TED, Jobst)

* Halos

* Immediate post-surgical or early fitting of prosthetic devices, etc.


SERVICES EXCLUDED FROM THE INPATIENT PAYMENT

The following services are excluded in the inpatient payment:

* An orthosis or prosthesis that is required for rehabilitation and will be utilized after discharge, and/or is required to address a long term, lifetime, permanent need. An orthotist/prosthetist must bill these items separately to Medicaid. Prior authorization (PA) must first be obtained for appropriate procedure codes.

* Except as noted above, outpatient services may not be separately billed while a beneficiary is in the inpatient setting. All charges must be included on the inpatient claim.

* Any services that are covered by Medicaid and excluded from the inpatient payment may be separately billed if the provider of the service is properly enrolled in the program and a claim is submitted appropriately.

The following are examples of services excluded from the inpatient payment. This list may not be allinclusive:

* Anatomic pathology services provided directly by a pathologist.

* Orthoses/prostheses required for rehabilitation that will be utilized after discharge, and/or are required to address a long term, lifetime, permanent need. Additional examples of items that are excluded from the inpatient payment are a knee-ankle-foot orthosis or an ankle-foot orthosis.


* Professional services (e.g., practitioner, dental, podiatric, optometric).

* Services provided by a certified nurse midwife (CNM).

* Services provided by a certified registered nurse anesthetist (CRNA).

* Ambulance services.




 Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) 

A.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 CPT code range 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 an Initial Hospital Care from CPT code range 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), from CPT code range 99234 – 99236, shall be reported.

D.Documentation Requirements for Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)

The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making documentation in the medical record shall include:

*Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;

*Documentation identifying the billing physician was present and personally performed the services; and

*Documentation identifying the admission and discharge notes were written by the billing physician.

E.Physician Services Involving Transfer From One Hospital to Another; Transfer Within Facility to Prospective Payment System (PPS) Exempt Unit of Hospital; Transfer From One Facility to Another Separate Entity Under Same Ownership and/or Part of Same Complex; or Transfer From One Department to Another Within Single Facility

Physicians may bill both the hospital discharge management code and an initial hospital care code when the discharge and admission do not occur on the same day if the transfer is between:

*Different hospitals;

*Different facilities under common ownership which do not have merged records; or

*Between the acute care hospital and a PPS exempt unit within the same hospital when there are no merged records.

In all other transfer circumstances, the physician should bill only the appropriate level of subsequent hospital care for the date of transfer.

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 CPT 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 CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

Subsequent hospital care CPT 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 CPT 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 CPT code for services that were reported as CPT 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 CPT 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 CPT 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.

Billing Initial Hospital Care and Discharge - multiple e & m service on Same Day

QUESTIONS AND ANSWERS

1 Q: If a patient is seen in the office at 3:00 p.m. and admitted to the hospital at 1:00 a.m. the next day, may both the office visit and the initial hospital care be reported?

A: Yes. Because different dates are involved, both codes may be reported. The CPT states services on the same date must be rolled up into the initial hospital care code. The term "same date" does not mean a 24 hour period. Refer to the CPT book for more information.


2 Q: May a physician report both a hospital visit and hospital discharge day management service on the same day?

A: No. The hospital visit descriptors include the phrase "per day" meaning they include all care for a day. Codes 99238-99239 (hospital discharge day management services) are used to report services on the final day of the hospital stay. To report both the hospital visit code and the hospital discharge day management services code would be duplicative.

3 Q: If a patient is admitted as an inpatient and discharged on the same day, may the hospital discharge day management code be reported?

A: No. To report services for a patient who is admitted as an inpatient and discharged on the same day, use only the appropriate code for Observation or Inpatient Care Services (Including Admission and Discharge Services) as described by CPT codes 99234-99236.



4 Q: May a physician or separate physician of the same group and specialty report multiple hospital visits on the same day for the same patient for unrelated problems?

A: No. The inpatient hospital visit descriptors contain the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single that reflects all services provided during the date of the service.

5 Q: In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, will Oxford pay physician B for the second visit? 

A: No. The inpatient hospital visit descriptors include the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single code that reflects all services provided during the date of the service.

6 Q: If a physician sees his patient in the emergency room and decides to admit the person to the hospital, should both services (the emergency department visit and the initial hospital visit) be reported? 

A: No. 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.

7 Q: If a patient is seen for more than one E/M or other medical service on a single date of service, and each service is performed by a physician with a different specialty designation, but in the same group practice, would each E/M or other medical service be separately reimbursable?

A: Yes, in certain circumstances. An E/M or other medical service provided on the same date by different physicians who are in a group practice but who have different specialty designations may be separately reimbursable. The Same Day/Same Service policy applies when multiple E/M or other medical services are reported by physicians in the same group and specialty on the same date of service. In that case, only one E/M is separately reimbursable, unless the second service is for an unrelated problem and reported with modifier 25. This would not apply when one of the E/M services is a "per day" code. For additional information regarding inpatient neonatal and pediatric critical care codes, CPT 99468-99480, reported by multiple physicians in the same group, see the policy titled Pediatric and Neonatal Critical and Intensive Care Services.


When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 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 an Initial Hospital Care from CPT code range 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), from CPT code range 99234 – 99236, shall be reported.

REIMBURSEMENT GUIDELINES for multiple e & m service on same day

The Medicare Claims Processing Manual states:

"Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the  combined visits and submit the appropriate code for that level.

Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.

In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.

If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses.”


The National Correct Coding Initiative Policy Manual states:

"Procedures should be reported with the most comprehensive CPT code that describes the services performed.

Physicians must not unbundle the services described by a HCPCS/CPT code.

A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services."

Consistent with Medicare, Oxford's Same Day/Same Service policy recognizes physicians or other health care professionals of the same group and specialty as the same physician, physician subspecialty is not considered.


According to correct coding methodology, physicians are to select the code that accurately identifies the service(s) performed. Multiple E/M services, when reported on the same date for the same patient by the same specialty physician, will be subject to edits used by and sourced to third party authorities. As stated above, physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.



D. Documentation Requirements for Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)

The physician shall satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation or hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making documentation in the medical record shall include:

• Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;

• Documentation identifying the billing physician was present and personally performed the services; and

• Documentation identifying the admission and discharge notes were written by the billing physician.

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.



A. 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.

Medicare rejection or Audit for incorrect POS

Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for Place of Service Billed by Physician Office and either Ambulatory Surgical Center or Inpatient Hospital 

The Medicare physician fee schedule includes two payment amounts depending on whether a service is performed in a facility setting, such as an outpatient hospital department or ambulatory surgical center, or in a non-facility setting, such as a physician’s office. The payments to physicians are higher when the services are performed in non-facility settings. The higher payments are designed to compensate physicians for the additional costs incurred to provide the service at an office location as opposed to a facility location.

The Office of Inspector General identified incorrect place of service billing by physicians as a payment error in an audit report (see A-01-11-00508).  This report stated, “Physicians are required to identify the place of service on the health insurance claim forms that they submit to Medicare contractors. The correct place-of-service code ensures that Medicare does not reimburse a physician incorrectly for the overhead portion of the payment if the service was performed in a facility setting.”  This report also states that several Medicare contractors overpaid physicians who did not correctly identify the place of service on their claims.

To ensure proper payment, CWF will create an IUR for all claims where the dates of service, the beneficiary information, and procedure, are all the same and billed with a physician place of service code 11 - office, and a facility code for inpatient hospital – 21, and ambulatory surgical center (ASC) – 24, that is posted due to an update from CMS.   An IUR is a message from CWF to a MAC, carrier or fiscal intermediary, as applicable, to review claims for accuracy.

The issue listed below has been identified by the recovery auditors as significant improper payments and requires the development of an edit to correct these improper payments.  The edit for this issue will include claims that have physician place of service code and either ambulatory surgical center (ASC) code or inpatient hospital code.  This edit will act as a tool to protect the Medicare Trust Fund by preventing improper billing practices.

Background:   

1)  An audit in October 2004 by the Office of the Inspector General (OIG) identified place of service billing by physicians as a payment error.  This report stated, “Medicare overpaid physicians due to incorrect place of service coding. Seventy-nine of 100 sampled physician services, selected from a population of services identified as having a high potential for error, were performed in a facility but were billed by the physicians using the “office” place of service code. As a result of the incorrect coding, Medicare paid the physicians a higher amount for these services.”  Because these claims cannot be denied prior to payment, CMS is implementing an IUR for all claim types to recover these payments.

CWF will create an Informational Unsolicited Response (IUR) for all claims where the dates of service, the beneficiary information, and procedure, are all the same and billed with a physician place of service code 11 - office, and a facility code for inpatient hospital – 21, and ambulatory surgical center (ASC) – 24, that is posted due to an update from CMS.

Initial Hospital Observation Care Billing

When may a physician bill for initial observation care?

When a physician decides to place a patient in “hospital observation” status, that patient has not formally been admitted to that hospital. The physician who placed the patient in “hospital observation,” is the only one who may care for the patient during his/her stay in observation, and the only one that may bill the hospital observation codes.

In order to bill the initial observation care codes, 99218 through 99220, the following must be created and maintained:

• A medical observation record for the patient which contains dated and timed physician’s admitting orders regarding the care the patient is to receive while in observation;
• Nursing notes; and
• Progress notes prepared by the physician while the patient was in observation status.

If applicable, this record is in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

When payment is made for an initial observation care code, it is for all the care rendered by the physician on the date the patient was placed in observation. All other physicians who see the patient in observation must bill the outpatient/office visit codes, or outpatient consultation codes, for the services they provide to that patient.

For example, if an internist admits a patient to observation and asks an allergist for a consultation on the patient’s condition, only the internist may bill the initial observation care code. The allergist must bill using the outpatient consultation code that best represents the services provided. The allergist cannot bill an inpatient consultation because the patient was not admitted as a hospital inpatient.

CPT CODE 99238, 99239 - Biling Guide

Hospital Discharge Day Management Codes 99238 and 99239

99238 Hospital discharge day management; 30 min.

99239 more than 30 min


A Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service between the attending physician and the patient.

Only the attending physician of record (or physician acting on behalf of the attending physician) shall report the Hospital Discharge Day Management Service (CPT code 99238 or 99239).

Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service (CPT codes 99238 or 99239).



Subsequent Hospital Visit and Hospital Discharge Day Management (Codes 99231 - 99239)


A.Subsequent Hospital Visits During the Global Surgery Period

The Medicare physician fee schedule payment amount for surgical procedures includes all services (e.g., evaluation and management visits) that are part of the global surgery payment; therefore, contractors shall not pay more than that amount when a bill is fragmented for staged procedures.

B.Hospital Discharge Day Management Service

Hospital Discharge Day Management Services, CPT code 99238 or 99239 is a face-to- face evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay.

Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range 99231 – 99233) for a final visit.

Medicare pays for the paperwork of patient discharge day management through the pre- and post- service work of an E/M service.

C.Subsequent Hospital Visit and Discharge Management on Same Day

Pay only the hospital discharge management code on the day of discharge (unless it is also the day of admission, in which case, refer to §30.6.9.1 C for the policy on Observation or Inpatient Care Services (Including Admission and Discharge Services CPT Codes 99234 - 99236). Contractors do not pay both a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician. Instruct physicians that they may not bill for both a hospital visit and hospital discharge management for the same date of service.

D.Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day

Contractors pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.

If a surgeon is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission and care with a modifier

“-24” and provides documentation that the service is unrelated to the surgery (e.g., return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge from the hospital for cholecystectomy).

Contractors do not pay for a nursing facility admission by a surgeon in the postoperative period of a procedure with a global surgical period if the patient’s admission to the nursing facility is to receive post operative care related to the surgery (e.g., admission to a nursing facility to receive physical therapy following a hip replacement).  Payment for the nursing facility admission and subsequent nursing facility services are included in the global fee and cannot be paid separately.

E.Hospital Discharge Management and Death Pronouncement

Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, CPT code 99238 or 99239.

The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date

Does time need to be documented in order to submit for a hospital or nursing facility discharge service?

Answer:

Yes, the time should be documented in the medical record to support the level of service billed for CPT codes 99238, 99239, 99315 and 99316.

Example: CPT code 99239 is used for a hospital discharge more than 30 minutes. Therefore, the discharge note would state, '45 minutes spent performing discharge services.'

Policy: 

The Medicare physician fee schedule payment for surgical procedures includes all the services and visits that are part of the global surgery payment including when such surgical procedures may be fragmented. Subsequent Hospital Care visits (Procedure  codes 99231 – 99233) are not separately payable when included in the global surgery payment. The Hospital Discharge Day Management Service (Procedure  code 99238 or 99239) is a face-to-face evaluation and management (E/M) service with the patient and his/her attending physician. Physicians shall use the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from Procedure  code range 99234 – 99236 for a hospital admission and discharge occurring on the same calendar date and when specific Medicare criteria, identified in §30.6.9.1, are met. The American Medical Association Current Procedural Terminology (Procedure ) codes 99238 and 99239 shall be paid only when they are performed face-to-face with the patient. Other physicians who manage the patient’s care (concurrent care) in addition to an attending physician, and who are not acting on behalf of the attending physician shall use the Subsequent Hospital Care codes from Procedure  code range Procedure  99231 – 99233 for a final visit with the patient. Medicare includes payment for general paperwork through the pre-and post-service work of E/M services. The physician who personally performs a patient pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service using Procedure  code 99238 or 99239. The date of death pronouncement shall reflect the calendar date of actual death pronouncement even if the paperwork is delayed to a subsequent calendar date.



Contractor shall instruct physicians and qualified NPPs that a Hospital Discharge Day Management Service (Procedure  code 99238 or 99239) is a face-toface E/M service between the attending physician and the patient.Contractor shall instruct physicians and qualified NPPs that only the attending physician of record (or physician acting on behalf of the attending physician)  shall report the Hospital Discharge Day Management Service (Procedure  code 99238 or 99239) .


Contractor shall instruct physicians and qualified NPPs that only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service (Procedure  codes 99238 or 99239).


Hospital Discharge Day Management Service

Hospital Discharge Day Management Services, Procedure  code 99238 or 99239 is a face-toface evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay.

Hospital Discharge Management (Procedure  Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day Contractors pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.

Hospital Discharge Management and Death Pronouncement Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, Procedure  code 99238 or 99239. The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date.

Hospital discharge day management codes 99238 (30 minutes or less) and 99239 (more than 30 minutes) are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient.   These codes include (as appropriate):   final examination of the patient; discussion of the hospital stay (even if the time spent by the physician on that date is not continuous); instructions for continuing care to all relevant caregivers; and preparation of discharge records, prescriptions and referral forms.

When reporting procedure codes 99238 or 99239, the medical record documentation should specify the amount of time involved in completing the patient’s hospital discharge day management.   If a physician bills the higher level of discharge day management, procedure code 99239, the total time spent rendering this service must be documented in the patient’s medical record indicating more than 30 minutes.  If procedure code 99239 is billed and no time is documented in the patient’s medical record, Highmark Medicare Services may reduce the service to the lower level of care, procedure code 99238.


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 CPT code range 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 an Initial Hospital Care from CPT code range 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), from CPT code range 99234 – 99236, shall be reported.

The Medicare physician fee schedule payment for surgical procedures includes all the services and visits that are part of the global surgery payment including when such surgical procedures may be fragmented. Subsequent Hospital Care visits (CPT codes 99231 – 99233) are not separately payable when included in the global surgery payment. The Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service with the patient and his/her attending physician. Physicians shall use the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from CPT code range 99234 – 99236 for a hospital admission and discharge occurring on the same calendar date and when specific Medicare criteria, identified in §30.6.9.1, are met. The American Medical Association Current Procedural Terminology (CPT) codes 99238 and 99239 shall be paid only when they are performed face-to-face with the patient. Other physicians who manage the patient’s care (concurrent care) in addition to an attending physician, and who are not acting on behalf of the attending physician shall use the Subsequent Hospital Care codes from CPT code range CPT 99231 – 99233 for a final visit with the patient. Medicare includes payment for general paperwork through the pre-and post-service work of E/M services. The physician who personally performs a patient pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service using CPT code 99238 or 99239. The date of death pronouncement shall reflect the calendar date of actual death pronouncement even if the paperwork is delayed to a subsequent calendar date. 

Medicare billing Guidelines

A. Subsequent Hospital Visits During the Global Surgery Period  The Medicare physician fee schedule payment amount for surgical procedures includes all services (e.g., evaluation and management visits) that are part of the global surgery payment; therefore, contractors shall not pay more than that amount when a bill is fragmented for staged procedures.

 B. Hospital Discharge Day Management Service Hospital Discharge Day Management Services, CPT code 99238 or 99239 is a face-toface evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if  he patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay.

Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range 99231 – 99233) for a final visit. Medicare pays for the paperwork of patient discharge day management through the preand post- service work of an E/M service.  

C. Subsequent Hospital Visit and Discharge Management on Same Day Pay only the hospital discharge management code on the day of discharge (unless it is also the day of admission, in which case, refer to §30.6.9.1 C for the policy on Observation or Inpatient Care Services (Including Admission and Discharge Services CPT Codes 99234 - 99236). Contractors do not pay both a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician. Instruct physicians that they may not bill for both a hospital visit and hospital discharge management for the same date of service.

D. Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day Contractors pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.

E. Hospital Discharge Management and Death Pronouncement

Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, CPT code 99238 or 99239. The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date. 

Separate payment may be made for an initial hospital visit (CPT codes 99221 through 99223), an initial inpatient consultation (CPT codes 99251 through 99255), and a hospital discharge service (CPT codes 99238 and 99239) when billed for the same date as an inpatient dialysis service. These services may be billed with a modifier -25 to indicate that they are significant and identifiable services.

Q: May a physician report both a hospital visit and hospital discharge day management service on the same day?

A: No. The hospital visit descriptors include the phrase "per day" meaning they include all care for a day. Codes 99238-99239 (hospital discharge day management services) are used to report services on the final day of the hospital stay. To report both the hospital visit code and the hospital discharge day management services code would be duplicative.

We will continue with the next time based code, hospital discharge services. There are two Procedure  Codes associated with hospital care discharge services. Procedure  Code 99238 represents less than 30 minutes spent on the discharge and Procedure  Code 99239 which is greater than 30 minutes spent on the discharge.

If the patient is discharged on the second calendar day, you may bill Procedure  Codes 99238 or 99239. If the patient is not discharged on day two and remains in the hospital, you may bill Procedure  Codes 99231 through 99233. Reminder: In order to submit any Procedure  Code, all documentation requirements must be met.

We highly recommend documenting the specific time when using Procedure  Codes 99238 or 99239. For example, if you spent 35 minutes performing the discharge service, documented 35 minutes. Avoid using statements such as, ‘greater than 30 minutes was spent performing discharge services.’

We would allow Procedure  Code 99238 if the time was not documented; however, we would down code Procedure  Code 99239 if the time was not documented. I cannot speak on behalf of any other entity such as the RAC, CERT, etc., so it is imperative to document appropriately.

Procedure  Codes 99238 and 99239 are a face-to-face evaluation and management service between the provider and the patient. The manuals state that only the principal physician of record may submit the hospital care discharge service. This code must be reported for the date the actual visit was performed, even if the patient is discharged from the facility on a different calendar date.

The hospital discharge codes 99238 or 99239 may be billed in addition to a nursing facility admission code when they are billed by the same provider with the same date of service. A surgeon who admits to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, may bill for the nursing facility admission care with Procedure  modifier 24.

Inpatient Dialysis On Same Date As Evaluation and Management.--Payment for certain evaluation and management services (CPT codes 99231 through 99233, subsequent  hospital visits, and CPT codes 99261 through 99263, follow-up inpatient consultations) is considered bundled into the payment for inpatient dialysis (CPT codes 90935 through 90947) when both are performed on the same day by the same physician for the same beneficiary. Do not pay a physician for both dialysis and a subsequent hospital visit or a follow-up inpatient consultation on the same date of service. If both are billed, pay the dialysis service and deny the evaluation and management service.

Separate payment may be made for an initial hospital visit (CPT codes 99221 through 99223), an initial inpatient consultation (CPT codes 99251 through 99255), and a hospital discharge service (CPT codes 99238 and 99239) when billed for the same date as an inpatient dialysis service. These services may be billed with a modifier -25 to indicate that they are significant and identifiable services.

Payment is not allowed for more than one inpatient dialysis service per day.


Hospital Discharge 99238 - 99239

** Discharge management includes:
** Final exam of patient
** Discussion of hospital stay
** Discharge instruction (including time to instruct family or other caregivers)
** Preparation of discharge records, prescriptions and referral forms
** Time – 30 minutes or less ~ 99238
** Time – More than 30 minutes ~ 99239
** Include all time even if not continuous on the same date

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 CPT code range 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 an Initial Hospital Care from CPT code range 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), from CPT code range 99234 – 99236, shall be reported.


QUESTIONS AND ANSWERS


Q: If a patient is seen in the office at 3:00 p.m. and admitted to the hospital at 1:00 a.m. the next day, may both the office visit and the initial hospital care be reported?

A: Yes. Because different dates are involved, both codes may be reported. The CPT states services on the same date must be rolled up into the initial hospital care code. The term "same date" does not mean a 24 hour period. Refer to the CPT book for more information.


Q: May a physician report both a hospital visit and hospital discharge day management service on the same day?

A: No. The hospital visit descriptors include the phrase "per day" meaning they include all care for a day. Codes 99238-99239 (hospital discharge day management services) are used to report services on the final day of the hospital stay. To report both the hospital visit code and the hospital discharge day management services code would be duplicative.


Q: If a patient is admitted as an inpatient and discharged on the same day, may the hospital discharge day management code be reported?

A: No. To report services for a patient who is admitted as an inpatient and discharged on the same day, use only the appropriate code for Observation or Inpatient Care Services (Including Admission and Discharge Services) as described by CPT codes 99234-99236.


Q: May a physician or separate physician of the same group and specialty report multiple hospital visits on the same day for the same patient for unrelated problems?

A: No. The inpatient hospital visit descriptors contain the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single code that reflects all services provided during the date of the service.


Q: In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, will Oxford pay physician B for the second visit?

A: No. The inpatient hospital visit descriptors include the phrase "per day" which means that the code and the payment established for the code represent all services provided on that date. The physician(s) should select a single code that reflects all services provided during the date of the service.


Q: If a physician sees his patient in the emergency room and decides to admit the person to the hospital, should both services (the emergency department visit and the initial hospital visit) be reported?

A: No. 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.


Q: If a patient is seen for more than one E/M or other medical service on a single date of service, and each service is performed by a physician with a different specialty designation, but in the same group practice, would each E/M or other medical service be separately reimbursable?

A:  Yes, in certain circumstances. An E/M or other medical service provided on the same date by different physicians who are in a group practice but who have differen specialty designations may be separately reimbursable. The Same Day/Same Service policy applies when multiple E/M or other medical services are reported by physicians in the same group and specialty on the same date of service. In that case, only one E/M is separately reimbursable, unless the second service is for an unrelated problem and reported with modifier 25. This would not apply when one of the E/M services is a "per day" code.