If a physician does not meet the documentation requirements for the lowest level initial hospital visit (99221), what code would be used?
CMS addressed this issue shortly after announcing that it would no longer accept CPT® inpatient consultation codes (99251-99255). MLN Matters® Number: SE1010 answers key questions on how to report inpatient E/M services in lieu of 99251-99255. Among them, the following Q&A states that subsequent hospital care codes (99231-99233) are appropriate if a service does not support the lowest-level initial inpatient visit (99221):
"Q. How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?
A. There is not an exact match of the code descriptors of the low-level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.” Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and 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."
The same MLN Matters article assures providers that Medicare contractors will allow for initial visits reported using subsequent care codes:
"Q. How will Medicare contractors handle claims for subsequent hospital care CPT codes that report the provider’s first E/M service furnished to a patient during the hospital stay?
A. While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code 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."
CMS provided this guidance in the context of reporting services in lieu of consultations, but most Medicare contractors have adopted the guidelines more broadly, to apply whenever an initial inpatient service does not meet the requirements of 99221.
Third party payers may follow different rules, with some payers specifying the use of unlisted E/M service code 99499. Check your contracts or contact the payer directly for its guidelines.