99251 and 99252

What advise do you have for the formerly inpatient billed codes 99251 and 99252 as these codes do not crosswalk to the lowest level inital inpatient visit code. We have posed the question to our local MAC; however, we have not yet had any response as to what they expect to see.

We had seen in a seminar that the unlisted code 99499 should be used for the formerly billed 99251 and 99252.

This does not appear to be the case as per the MLN Matters Number: MM6740 as in the article it states, "in all cases, physicians will bill the available code that most appropriately describes the level of the services provided."

Are we supposed to use the 99221 eventhough what we formerly may have billed would not have the detailed history and exam?

Thanks,

99251 and 99252

No, don't use 99221 if you don't have a detailed history or exam.

Some MACs are saying use 99499: Palmetto, WPS, First Coast.

Others are saying don't use it, which I take to mean, use the subsequent hospital visits, although they don't always say: Trailblazer, Noridian, Cigna.

CMS isn't telling the MACs which code to accept in this instance. Helpful,eh?

I read somewhere

and I could shoot myself for not keeping it- that CMS said that the first encounter with the patient in the hospital must be billed as an initial hospital visit, which means 99221. I wish I could find that reference...

The closest I could come was http://www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf
which says "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."

Doesn't meet 99251 or 99252

I think the transmittal was vague: "appropriate E/M code" so CMS is letting the MACs decide what to bill if it doesn't meet the criteria of a 99221. I don't think they are instructing us to use that if the documentation doesn't support it.

I disagree

CMS says "All physicians who provide an initial visit to a patient during hospital care 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 with 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."

and they say "In the inpatient hospital setting and the nursing facility 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)"

from http://www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf

There is no except if the service does not meet the documentation requirements or any other qualifier. The first quote says SHALL- that is pretty definitive to me.

but what if it doesn't meet the criteria for a 99221?

Do you think that the payers will deny the claim if 99221 isn't first? Or, are you saying, they HAVE to (because of the word shall) and if they don't they won't get paid?

Honestly, I think most consults (Or what were consults) will be documented at the 99221 level. But, some may miss on exam. If they do, I prefer to use the subsequent hospital visits, not the unlisted code (unless the MAC says you have to) because the processing will be quicker.

The subsequents are two of three, so easier to meet the requirements.

I hear ya!

Inpatient overcoding is rampant but no one ever gets audited so docs really care.

I really think that CMS's intent is that the INITIAL visit, no matter how simple or how little documentation is done, gets coded with an INITIAL visit code. And the lowest code is 99221. And that is what I will teach my docs and I'll go to court to defend them on it.

A MAC medical director posted this...

On another listserv, a MAC medical director posted this, about the topic of what to bill if the visit doesn't meet the criteria of a 99221:

Note to all: many of us understand - and share the feeling - that this has been confusing and frustrating.
Expect a further CMS release very shortly on these issues. (Unable to relay anything further, but may help to know this.)


That's good news! CMS made this change very quickly.

99251 and 99252

This is sure going to pose lots of issues for CERTS and RACS for auditing these visits, when the guidance is not 100% clear and not crosswalks were created for this change.

There is one line in the MLN Matters Article MM6740 that states, "In all cases, physicians will bill the available code that most appropriately describes the level of services provided." on pg 3 of 8.

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf

However, since the visit does not match the level of service as per CPT the "available code" would be the unlisted code unless it is not truly a consult code anyway, but rather a transfer of care. We have a hard time determining that ourselves since we are a general and vascular surgical practice. Dr. So and So asks us to see the patient for a hot gallbladder, we are going to take it out, was he really requesting our opinion that the gallbladder needed to come out, or actually transferring care of that problem to us in the first place. The whole reason they want to do away with the consult codes.

So why not take this perfectly good code set and change what it is used for... for example, why not use the 99251-99255 as the initial hospital care codes and use the 99221 - 99223 for the admission to inpatient care codes. Delete the office consultation codes all together and make them either new or established and so forth. That would make things much less confusing and less of a headache for everyone, auditors included...