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Initial Facility Services (Q&As)

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In this document, we will use the term "physician" to indicate both physicians and nonphysician practitioners.

Question 1: When the physician provides a direct admit from the office, can we bill an initial hospital visit even though the physician does not go to the hospital on that day?

Answer: No. An initial hospital visit code is the first encounter with the patient as an inpatient in the hospital. Billing an initial hospital visit procedure code is not appropriate if the physician does not see the patient in the hospital. The physician would bill the office visit and then bill the initial visit code when he/she sees the patient in the hospital. If the physician sees the patient in the hospital on the same day as a visit in another site of service, only the initial hospital visit may be billed.

Question 2: Please confirm that only the "admitting" physician can use an initial hospital care code. How do you define "admitting" versus "attending?" Dr. A admits Mr. Smith to the hospital. Dr. A makes a brief visit and writes orders for Mr. Smith's medications. The next day, Dr. B, Mr. Smith's attending physician sees Mr. Smith and meets the criteria for a 99222. What service should Dr. A and Dr. B submit to Medicare?

Answer: For services January 1, 2010, and after CMS discontinued the use of consultation codes for Medicare services and as part of this change, more than one physician may bill an initial inpatient visit. Physicians other than the "admitting", "attending" or the "principle physician of record" may bill an initial visit when the medical documentation supports the level of service and a member of the same group with the same specialty did not previously provide an initial inpatient service. The principle physician of record appends modifier AI to their initial inpatient service.

If the documentation for the initial visit does not support one of the initial inpatient procedure codes, CMS has instructed contractors to not find fault with the physician billing a subsequent care procedure instead.

For services prior to January 1, 2010, according to the CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.9.1.G, only the admitting physician of record may bill the initial hospital visit procedure codes. Only one physician may be the admitting physician. CMS has not provided a definition of admitting and/or attending physician. Medicare defines the principle physician of record as the physician responsible for the patient's care will inpatient.

Question 3: Can the admission to a Skilled Nursing Facility (SNF) or Nursing Facility (NF) be performed from the hospital? Is there a requirement that the patient must be seen physically in the home within a certain time period?

Answer: We received confirmation from CMS on this question. When the physician is performing the assessment for the admission to the SNF or NF at the hospital, the physician may bill this using place of service (POS) 31 - SNF or 32 - NF. If the patient is discharged from the hospital and admitted to the SNF or NF on the same day, both services may be approved by Medicare when the physician provides both services. You can find more information in the IOM Publication 100-04, Chapter 12, Section 30.6.9.2 D. There are requirements as to the time-frame for the assessment and plan of care for the patient in a SNF. You can find more information in the IOM Publication 100-04, Chapter 12, Section 30.6.13.

Question 4: Please help me to better understand outpatient observation to acute inpatient. If the patient is admitted to observation status on Monday, admitted to an inpatient history on Tuesday, and then discharged from inpatient status on Wednesday. How would we bill these services?

Answer: The admission of a patient in observation status is procedure codes 99218 - 99220. The admission of the patient to inpatient status on Tuesday is procedure codes 99221 - 99223. The discharge on Wednesday is procedure codes 99238 - 99239. The code chosen is based on where the service is provided and the level of care provided. You can find more information on observation services in the IOM Publication 100-04, Chapter 12, Section 30.6.8.D.

Question 5: Patient admitted to observation and admitted to the hospital the next day, the service does not meet the definition of an initial visit. Do we bill subsequent visit or not otherwise classified (NOC)?

Answer: An initial visit is the first time the admitting physician sees the patient in the inpatient setting. If the service provided does not meet the definition of the lowest level of initial hospital visit, 99221, CMS has instructed contractors to not find fault with a provider using a subsequent level of care procedure code. The use of the NOC code should be very rare.

Question 6: One physician admits the patient to observation care, another physician admits the patient as an inpatient later in the day. How do we bill this to Medicare when the physicians are members of the same group with the same specialty and when they are not members of the same group?

Answer: When the physicians are members of the same group with the same specialty, Medicare considers them to be the same physician and, therefore, will only reimburse the initial hospital procedure code. The documentation should be combined to show the totality of the service. Physicians who are not members of the same group or members of the same specialty within the same group, may bill separately for their medically necessary services.

Question 7: I am the admitting physician for the patient and today is the first day I see the patient. However, my documentation does not support the level of service for a 99221. Should I bill an NOC code or code to a subsequent care code?

Answer: If your level of documentation does not support the procedure code 99221, CMS has instructed contractors to not find fault with a provider using a subsequent care procedure code. The use of the NOC 99499 should be very rare.

Question 8: The patient was admitted to the hospital on the 10th, but I did not see the patient until the 11th. Should I bill the initial visit on the 10th or 11th?

Answer: You would not be able to submit charges for the 10th as you did not see the patient on that day. The admitting physician bills the initial hospital visit the first time he/she sees the patient in the hospital. You can only bill the initial visit on the day it was performed - the 11th.

Question 9: I admitted the patient on the 10th and saw them briefly. I performed the history and physical (H&P) on the 11th. Can I bill a subsequent code on the 10th and the hospital admission on the 11th?

Answer: The initial hospital visit procedure codes are used the first time the admitting physician sees the patient in the hospital. In the example, the initial visit is on the 10th. Choose the procedure code based on the documentation. If your documentation does not support the use of the lowest initial inpatient procedure code, 99221, then submit a subsequent procedure code. The service on the 11th is a subsequent hospital visit.

Question 10: I saw the patient in my office, completed an H&P, and sent them to the hospital for admission. Can I bill an initial hospital visit?

Answer: No. The physician may bill an initial hospital visit only when he/she sees the patient for the first time in the inpatient setting.

Question 11: I saw the patient in the office on Tuesday and determined they needed to be admitted to the hospital. I sent the patient to the hospital and called with the instructions for their stay. Should I bill the initial hospital visit on Tuesday or when I went to the hospital on Wednesday?

Answer: The service provided on Tuesday is an office visit. Bill the initial visit the first time that you see the patient in the hospital. As you did not see the patient in the inpatient facility on Tuesday, you cannot bill for an initial inpatient service on Tuesday.

Question 12: The patient is discharged from the acute care hospital and admitted to an Inpatient Rehabilitation Facility (IRF) on the same day. Can we bill a discharge visit and an admission on the same day when performed by the same physician?

Answer: No. The CMS IOM Publication 100-04, Chapter 12, Section 30.6.9.1.E states that when a transfer from one facility to another occurs, the physician may bill a subsequent hospital visit code.

Page Last Updated: Thursday, 17-Jul-2014 09:22:20 CDT