Monday, February 9, 2015

CPT code 99221, 99223, 99222 and 99233 - Inpatient hospital visits

99221 : Inpatient hospital visits: Initial and subsequent

initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and 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 problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.

99222 : Inpatient hospital visits: Initial and subsequent

initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and 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 problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.

99223 : Inpatient hospital visits: Initial and subsequent


initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and 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 problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit.



Payment for Initial Hospital Care Services (Codes 99221 - 99223) 

A. Initial Hospital Care From Emergency Room Carriers pay for an initial hospital care service or an initial inpatient consultation if a physician sees his/her patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

B. Initial Hospital Care on Day Following Visit Carriers pay both visits if a patient is seen in the office on one date and admitted to th 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  Carriers pay only the initial hospital care code when a patient is admitted as an inpatient and discharged on the same day. They do not pay the hospital discharge management code on the date of admission. Carriers must instruct physicians that they may not bill for both an initial hospital care code and hospital discharge management code on the same date.

D. 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:

1. Different hospitals;

2. Different facilities under common ownership which do not have merged records;

or

3. 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.

E. Initial Hospital Care Service History and Physical That Is Less Than Comprehensive When a physician performs a visit or consultation that meets the definition of a Level 5 office visit or consultation several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit or consultation that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Carriers pay the office visit as billed and the Level 1 initial hospital care code.

F. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same Admission Physicians use the initial hospital care codes (codes 99221-99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician. Carriers consider only one M.D. or D.O. to be the admitting physician and permit only the admitting physician to use the initial hospital care codes. Physicians that participate in the care of a patient but are not the admitting physician of record should bill the inpatient evaluation and management services codes that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient consultation).

G. Initial Hospital Care and Nursing Facility Visit on Same Day Pay only the initial hospital care code if the patient is admitted to a hospital following a nursing facility visit on the same date by the same physician. Instruct physicians that they may not report a nursing facility service and an initial hospital care service on the same day. Payment for the initial hospital care service includes all work performed by the physician in all sites of service on that date.


B. Requirement for Physician Presence

Physicians may count only the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical time of the visit code billed to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable. In the case of prolonged office services, time spent by office staff with the patient, or time the patient remains unaccompanied in the office cannot be billed. In the case of prolonged hospital services, time spent waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities cannot be billed as prolonged services.

C. Documentation

Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the evaluation and management code billed and to show that the physician personally furnished the time specified in the HCPCS code definition.


Threshold Time to Bill Codes 99221 - 992333

99221 30 60 105
99222 50 80 125
99223 70 100 145
99231 15 45 90
99232 25 55 100
99233 35 65 110


Initial Hospital Care 99221 99222 99223 Time Typically 30 min Typically 50 min Typically 70 min

• Unit/floor time includes:

– Provider present on patient’s hospital unit and at the bedside rendering services to the patient
– Reviewing the patient’s chart
– Examining the patient

Time Typically 30 min Typically 50 min Typically 70 min g p

– Writing notes/orders

– Communicating with other professionals and the patient’s family on the patient’s floor Inpatient Consults…according to Medicare

• Effective January 1, 2010, the consultation codes are no longg p er recognized for Medicare part B payment

• 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).


Prepayment review for initial and subsequent hospital evaluation and management services CPT® codes 99223 and 99233

Data Analysis due to the high Comprehensive Error Rate Testing (CERT) error rates for evaluation and management services pertaining to Current Procedural Terminology® (CPT®) codes 99223 (initial hospital visit) and 99233 (subsequent hospital visit). The CERT November 2014 forecasting report indicates a projected error rate of 39.8 percent for CPT® code 99223 and a projected error rate of 34.4 percent for CPT code 99233. The data indicates that the specialty of internal medicine is the primary contributor to the CERT error rate: internal medicine error rates are currently trending at 36.6 percent for CPT® code 99233 and 33.3 percent for CPT® code 99223.

Documentation requirements

The American Medical Association (AMA) CPT® manual defines code 99223 as follows:
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:

• A comprehensive history;
• A comprehensive examination; and
• 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’s needs. Usually, the problem(s) requiring an admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital unit.

First Coast response on Audit Update

In response to the high percentage of error rates and continual risks of improper payments associated with initial hospital care visits, First Coast will implement a prepayment threshold audit for CPT® code 99223 claims submitted on or after July 25, 2017, and this audit will apply to all provider specialties (with the exception of claims for 99223 for provider specialties 06-Cardiology and 11-Internal Medicine, as there is currently a separate prepayment threshold audit in place for these provider specialties). The new audit will be based on a predetermined percentage of claims in an effort to reduce the error rates for these hospital services.

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 2 of these 3 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 unit.



Key points to remember

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

The key components (elements of service) of evaluation & management (E/M) services are:
1. History
2. Examination
3. Medical decision-making

When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), 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.

Tips pertaining to different types of E/M services can be located by accessing the links in the table below:


CPT code range    Type of E/M service

99201-99205    Office or other outpatient E/M services for new patients

99211-99215    Office or other outpatient E/M services for established patients

99221-99223    Initial hospital care E/M services

99231-99233    Subsequent hospital care E/M services

96150-96152, G0425-G0427    Telehealth Services



CPT Code 99223  Inpatient Hospital Care

Initial Hospital Care:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

• Comprehensive history
• Comprehensive exam
• Medical Decision making of HIGH complexity

Comprehensive History:

• Chief complaint/reason for admission
• Extended history of present illness (HPI)
- Extended consists of four or more elements of the HPI
• Review of systems directly related to the problem(s) identified in the history of present illness
• Medically necessary review of ALL body systems’ history
• Medically necessary complete past, family and social history
• Four or more elements of the HPI or the status of at least three (3) chronic or inactive conditions, noting that medical necessity is ALWAYS the overarching criterion

HPI – History of Present Illness:

A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include:
• Location
• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs/symptoms significantly related to the presenting problem(s)

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 encounte

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


Past, Family, and/or Social History (PFSH):

Consists of a review of the following:

• Past history (patient’s past experiences with illnesses, operations, injuries,
and treatments

• Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk)

• Social History (an age appropriate review of past and current activities



Additional Information:

• If patient is admitted to the hospital during an encounter in another setting (i.e. physician  office, nursing home, emergency room) and on the same date of service as the admission all E/M services provided by that physician in conjunction with the admission are considered part of the initial hospital care.

• Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E/M codes UNLESS their presence significantly increases the complexity of the medical decision making.

• Practitioner’s choosing to use time as the determining factor:
- MUST document time in the patient’s medical record
- Documentation MUST support in sufficient detail the nature of the counseling
- Code selection based on total time of the face-to-face encounter (floor time), the medical  record MUST be documented in sufficient detail to justify the code selection
• Face-to-face time refers to the time with the physician ONLY. The time spent by other staff is NOT considered in selecting the appropriate level of service

Billing and Coding Guidelines


Hospital Visit and Critical Care on Same Day

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

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.

Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice

Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for  the same patient on the same calendar date as other E/M services.


 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,

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.


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

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.

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



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.


CPT Code 99233 Subsequent Hospital Care

Subsequent Hospital Care:

Subsequent hospital care, per day, for the evaluation and management of a patient which requires at least 2 of these 3 key components:

• Detailed interval history
• Detailed examination
• Medical decision making of HIGH complexity


Detailed Interval History:

• Reason for admission
• Problem pertinent review of systems
• Extended history of present illness (HPI)
- Extended consists of four or more elements of the HPI
• Pertinent past family/social history – Directly related to the patient’s problem
• Review of the following:
- Medical Record
- Results of diagnostic tests/studies
- Current assessment/status
- Changes in patient’s status
▪ Changes in history
▪ Changes in physical or mental status
▪ Response to management/treatment


HPI – History of Present Illness:

A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include:

• Location
• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs/symptoms significantly related to the presenting problem(s)


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

Past, Family, and/or Social History (PFSH):

Consists of a review of the following:

• Past history (patient’s past experiences with illnesses, operations, injuries, and treatments)
• Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk)
• Social History (an age appropriate review of past and current activities)


Medical Decision Making of High Complexity

(Documentaton must meet or exceed 2 of the following 3):
• Extensive management options for diagnosis or treatment
• Extensive amount of data to be reviewed consisting of the following:
- Lab/Diagnostic/Imaging results
- Charts/notes from other practitioner’s (i.e. PT, OT, consultants)
- Documentation of labs or diagnostics still needed
• High risk of complications and/or morbidity or mortality
- Comorbidities associated with the presenting problem
- Risk(s) of diagnostic procedures(s) performed
- Risk(s) associated with possible management options


Additional Information:

• Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E/M codes UNLESS their presence significantly increases the complexity of the medical decision making.
• Practitioner’s choosing to use time as the determining factor:
- MUST document time in the patient’s medical record
- Documentation MUST support in sufficient detail the nature of the counseling
- Code selection based on total time of the face-to-face encounter (floor time), the medical record MUST be documented in sufficient detail to justify the code selection
• Face-to-face time refers to the time with the physician ONLY. The time spent by other staff is NOT considered in selecting the appropriate level of service


Hospital care code billing as as consult code

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


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


The following are edit types that may be applied in the Same Day Same Service Policy.

CCI Definitive: An edit sourced to specific billing guidelines from the General Correct Coding Policies contained in the National Correct Coding Policy Manual published by CMS. For example, the Evaluation and Management Services section (chapter xi) specifically states "A physician should not report an 'initial' per diem E&M service with the same type of 'subsequent' per diem service on the same date of service." UnitedHealthcare will not separately reimburse for an initial and a subsequent per diem service on the same date, such as 99223 and 99232.

CMS Definitive: An edit sourced to a specific billing guideline from CMS. For example, the Medicare Claims Processing Manual states "If the same physician who admitted a patient to observation status also admits the patient to inpatient status from observation before the end of the date on which the patient was admitted to observation, pay only an initial hospital visit for the evaluation and management services provided on that date." UnitedHealthcare will not separately reimburse for an initial observation care service on the same date as an initial hospital care service, such as 99218 and 99222.


Medicaid Billing Guide - INPATIENT HOSPITAL

An inpatient hospital is defined as a facility, other than psychiatric, which primarily provides medically necessary diagnostic, therapeutic (both surgical and nonsurgical) or rehabilitation services to inpatients. Services provided to inpatients include bed and board; nursing and other related services; use of facility; drugs and biologicals; supplies, appliances and equipment; diagnostic, therapeutic and ancillary services; and medical or surgical services. Services of professionals (e.g., physician, oral-maxillofacial surgeon, dental, podiatric, optometric) are not included and must be billed separately. Inpatient hospital services are:

* Ordinarily furnished in a facility for the care and treatment of inpatients.

* Furnished under the direction of a physician (MD or DO) or a dentist.

* Furnished in a facility that is:

* Maintained primarily for the care and treatment of inpatients with disorders other than mental diseases;

* Licensed or formally approved as a hospital by an officially designated authority for State standard-setting; and

* Medicare-certified to provide inpatient services.

An inpatient is an individual who has been admitted to a hospital for bed occupancy with the expectation that he will remain at least overnight, even when it later develops that he can be discharged or is transferred to another hospital and does not use the bed overnight. Days of care provided to a beneficiary are in units of full days, beginning at midnight and ending 24 hours later. Medicaid covers the day of admission but not the day of discharge. If the day of admission and the day of discharge are the same, the day is considered an admission day and counts as one inpatient day.


OUTPATIENT HOSPITAL

An outpatient hospital (OPH) is defined as a portion of a hospital that provides diagnostic, therapeutic(both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require  inpatient hospitalization. Outpatient hospital services are:

* Furnished under the direction of a physician (MD or DO) or a dentist.

* Furnished in a facility that is certified as a provider, or as having provider-based status, by Medicare.

To facilitate coordination of benefits, MDHHS follows Medicare’s coverage policies as closely as possible and appropriate. Differences in coverage policy are described in this chapter.

COPAYMENT

Copayments may be required for inpatient hospital stays, outpatient hospital visits, and non-emergency visits to the Emergency Department for beneficiaries age 21 years and older. Enrollees in the Breast and Cervical Cancer Control Program (BCCCP) are exempt from co-pays. Native American Indians/Alaska Natives are exempt from co-pays consistent with federal regulations at 42 CFR §447.56(a)(1)(x).

The copayments are:

* $50 for the first day of an inpatient stay (applies to DRG or first day per diem payment; copay will not be applied to emergent admissions, transfers between acute care hospitals, from acute care to rehab, or to readmits within 15 days for the same DRG/diagnosis)


* $1 for an outpatient hospital clinic visit

* $3 for non-emergency visit to the Emergency Department Federal regulations at 42 CFR §447.54 specify the cost-sharing requirements for services provided in a hospital emergency department. To impose cost sharing for non-emergency services provided in a hospital emergency department, the hospital must:

* Perform appropriate medical screening under 42 CFR §489.24 Subpart G to determine the individual does not need emergency services.

* Before providing nonemergency services, inform the individual of the amount of cost sharing responsibility for non-emergency service(s).

* Provide the individual with the name and location of an available and accessible alternative nonemergency services provider; determine that the alternative provider can provide services in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the person is otherwise exempt from cost sharing; and provide a referral to coordinate scheduling for treatment with the alternative provider.

Hospitals providing emergency department services are expected to develop cost sharing policies and procedures consistent with the federal requirement.



Payment for Inpatient Hospital Visits - General


A.Hospital Visit and Critical Care on Same Day

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

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.

Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.

B.Two Hospital Visits Same Day

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.

C.Hospital Visits Same Day But by Different Physicians

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. There are circumstances where concurrent care may be billed by physicians of the same specialty.

D.Visits to Patients in Swing Beds

If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.

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