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More on billing for inpatient services; emergency department coding rule change


Understand how to bill inpatient services.

Key Points

Q: With new rules from the Centers for Medicare and Medicaid Services (CMS) regarding consultations, we still are confused as to how to bill inpatient services. We have been told to bill several different ways, including using 99499, subsequent hospital codes, and initial inpatient codes. Which way is correct?

The outpatient consultation codes (99241–99245) crosswalk to the new outpatient codes (99201–99205). The elements are very different when trying to choose the inpatient codes that correspond to the lower-level inpatient consultation codes, however. Therefore, Medicare carriers are advising practices to report these services with a variety of codes, including unlisted evaluation/management code 99499 and subsequent hospital care codes 99231 and 99232.

The bottom line is, the determination of which of your scenarios is correct depends on the carrier and what the documentation supports.

Other questions to ask your carrier. Given the confusion that the changes have brought, some carriers are giving leeway in the areas listed below, so check with your carrier to see how it is reimbursing in these situations.

• Some Medicare carriers have instructed providers that the "AI" modifier (to be appended to the admitting physician's initial hospital care code) usage will not determine reimbursement. Therefore, if the admitting physician fails to append the AI modifier or the non-admitting physician appends it inappropriately, the initial inpatient service code still will be paid.

• National Government Services (NGS), a large Medicare contractor, also has instructed providers that it will pay for a subsequent hospital care code without an initial hospital care code billed. This action means that NGS recognizes that a subsequent care code could be billed for a provider's initial hospital care.


Q: Can a specialist called to the emergency department (ED) bill codes 99281–99285? We've heard that those codes are reserved for the ED physician.

A: As of January 1, CMS implemented a rule change regarding ED coding. Previously, the evaluating physician (in the scenario you describe, the specialist) would have reported an outpatient (office) code for an ED exam (if he or she didn't use a consultation code), because the patient had not been admitted as an inpatient. Currently, if an ED physician requests that another physician evaluate a patient (formerly a consultation service), CMS stipulates that "the other physician should bill an [ED] visit code." If the patient is admitted to the hospital by the second physician performing the evaluation, however, then the second physician should report an initial hospital visit care code instead.

Additionally, CMS states that if the patient's personal physician evaluates the patient in the ED at the request of the ED physician and advises that the patient be sent home, then both the ED physician and the patient's personal physician would report the appropriate ED code. Remember, the patient's personal physician cannot bill if he or she only advises the ED physician by telephone.

The author is a compliance manager for Baptist Medical Associates in Louisville, Kentucky. Do you have a coding question for our experts? Send it to

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Jennifer N. Lee, MD, FAAFP
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