Additionally, a consultation service (99251–99255) should not be reported, because the request involves the completion of a facility-mandated form and not an opinion or advice on caring for the patient. If medical issues require the hospitalist’s evaluation and management, there is medical necessity for capturing the hospitalist’s participation as subsequent hospital care (99231–99233). If no medical conditions present for the hospitalist to manage, the service will not be considered “medically necessary” by the payor.
Interfacility
Hospitalist groups provide patient care and coverage in a variety of facilities. Confusion often arises when the attending of record during acute care and the sub-acute setting are different hospitalists from the same HM group. The hospitalist who receives the patient in the transfer facility may err on the side of caution and report subsequent hospital care (99231–99233) because the group has provided ongoing patient care. In this scenario, the hospitalist group might lose revenue if an admission service (99221–99223) was not reported.
Day of Transfer Billing
A single hospitalist or two hospitalists from the same group might bill both the hospital discharge management code (99238–99239) and an initial hospital care code (99221–99223) when the discharge and admission do not occur on the same day if the transfer is between:
- Different hospitals;
- Different facilities under common ownership that do not have merged records;* or
- Between the acute-care hospital and a prospective payment system (PPS)-exempt unit within the same hospital when there are no merged records.
In all other transfer circumstances that do not meet the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231–99233) for the date of transfer.1 Of note, Medicare Part A covers inpatient care in psychiatric, rehabilitation, critical access, and long-term-care hospitals. Each of these specialty hospitals is exempt from the PPS established for acute-care hospitals in 1983.2 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
*Editor’s note: “Merged record” is not equivalent to commonly accessible charts via an electronic health record system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.
References
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1E. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
- Department of Health and Human Services. Office of Inspector General: Oversight of Medicare PPS-Exempt Hospital Services. HHS Web site. Available at: www.oig.hhs.gov/oei/reports/oei-12-02-00170.pdf. Accessed June 1, 2009.
- CMS. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1H. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.