In the expansion category of the 2021 documentation guidelines, there’s some information that may be a little confusing that would like to review with you in Today’s Take. On page 23, under Initial Hospital Inpatient or Observation Care, under the New and Established Patient, there’s a paragraph that reads a little confusing:
“If a consultation is performed in anticipation of, or related to, an admission by another physician or other qualified health care professional, and then the same consultant performs an encounter once the patient is admitted by the other physician or other qualified health care professional, report the consultant’s inpatient encounter with the appropriate subsequent care code (99231, 99232, 99233). This instruction applies whether the consultation occurred on the date of the admission or a date previous to the admission. It also applies for consultations reported with any appropriate code (eg, office or other outpatient visit or office or other outpatient consultation).”
This paragraph could be a little bit confusing because it could be inferred what exactly we can bill in conjunction with an inpatient encounter.
An example that might make better sense of this type of situation is an emergency room physician asking a cardiologist to consult on a patient in the ED. Cardiology sees the patient in the emergency room and then later, let’s just say within the same 24 hours, the hospitalist goes into the emergency room and admits that patient. Within the same 24-hour episode, Cardiology comes in and sees that patient again. This rule explains that you cannot bill for a consult in the ED and then turn around and bill for an initial in the inpatient setting. Now all of us should think “Oh, that makes sense!”
That’s all that rule is saying. It’s taking what we already know and spelling it out so that it makes sense (just in a roundabout way).
What I want to point out here is what’s not included in that rule. It never really tells us that we can combine the work. It doesn’t say, “oh but wait a minute, we know in theory you’ve performed two services, so what you can do is take the work of that consult and the work of that initial visit, and you can combine the work of both of those services and use them to support one service code.” Now yes, that does make sense, but I do want to caveat here that there is no rule in those guidelines that says you may do that. You may want to check reimbursement policy. I want to make this perfectly clear, there is a fundamental difference between coding policy and reimbursement policy. Coding policy says this is how you use the code to get paid, and the code rule is how you use the code. The reimbursement policy says, I am who is paying you to see our beneficiary, and I can have my own rule because you signed the PAR agreement to see our patients. When you signed that PAR agreement, you agreed to abide by our medical policies to see our patients and to get paid to see our patients. So, there are two sets of fundamental rules must be adhered to. Now that may be AMA and CMS, it could be AMA and BlueCross/Blue Shield. You may want to check and see if they have a policy. But I’m going to tell you that when we look at what the AMA policy says here, there is no coding guidance there that says, well, actually, you can add the work of those two services together and fundamentally use them both to support the service. Be careful what we assume is an allowed privilege, because nowhere does it say it is.
Be sure watch the YouTube video on this topic and don’t forget NAMAS has resources to help you with inpatient services! We have hands-on E&M webinars. We have our inpatient reference sheets. All types of inpatient resources are available on our website. If you have any questions or comments, anything I can help you with, please let me know at namas@namas.co.
Your next steps:
- Contact NAMAS for information about customized staff and provider training.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
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