Provider Types Affected

Physicians and qualified nonphysician practitioners (NPP) who bill Medicare carriers and Medicare Administrative Contractors (A/B/MAC) for inpatient services provided to Medicare beneficiaries

What You Need to Know

CR 5793, from which this article is taken, updates initial hospital care policy found in the Medicare Claims Processing Manual that includes admission and discharge services on the same calendar date of service. It advises physicians and NPPs of which Current Procedural Terminology (CPT) codes to use when inpatient hospital care is less than eight (8) hours on the same calendar date, when a patient is admitted and discharged on a different calendar date, and when admitted for eight (8) hours but less than 24 hours on the same calendar date. It also identifies medical record documentation requirements.

Background

CR 5793, from which this article is taken, updates initial hospital care policy found in the Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 30.6.9.1 (Payment for Initial Hospital Care Services (Codes 99221–99223 and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Codes 99234 – 99236). It advises physicians and NPPs of the correct CPT codes to use when inpatient hospital care is less than eight hours on the same calendar date, when a patient is admitted and discharged on a different calendar date, and when admitted for eight hours but less than 24 hours on the same calendar date; and identifies medical record documentation requirements.

This physician payment policy was finalized in the Medicare Physician Fee Schedule Final Rule, dated November 1, 2000, Vol. 65, No. 212, pp. 65408 – 65409 with the implementation of the American Medical Association Current Procedural Terminology (CPT) codes for CPT 2001.

Specifically, CR 5793 reminds physicians and qualified NPPs that:

• When a patient is admitted to inpatient hospital care for less than eight hours on the same calendar date, you shall report the Initial Hospital Care using a code from CPT code range 99221 – 99223. In this scenario, do not use the Hospital Discharge Day Management Service, CPT code 99238 or 99239;
• When a patient is admitted for inpatient hospital care and discharged on a different calendar date, you shall report the Initial Hospital Care using a code from CPT code range 99221 – 99223 and CPT code 99238 or 99239 for a Hospital Discharge Day Management Service; and
• When a patient is admitted to inpatient hospital care for a minimum of eight (8) hours but less than 24 hours and discharged on the same calendar date, you shall report the Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services Same Day) using a code from CPT code range 99234 – 99236, and no additional discharge service.

Remember that your medical record documentation must meet the evaluation and management (E/M) documentation requirements for history, examination and medical decision making. For reporting CPT codes 99234 – 99236 the medical record shall include:

• Documentation stating the stay for hospital treatment or observation care status involves eight (8) hours but less than 24 hours;
• Documentation identifying the billing physician was present and personally performed the services; and
• Documentation identifying the admission and discharge notes were written by the billing physician.

Additional Information

You can find more information about the correct CPT codes to use for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) by going to CR 5793 located at http://www.cms.hhs.gov/Transmittals/downloads/R1465CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. You will find the updated Medicare Claims Processing Manual Chapter 12 (Physicians/Nonphysician Practitioners), Section 30.6.9.1 (Payment for Initial Hospital Care Services (Codes 99221–99223 and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Codes 99234 – 99236) as an attachment to that CR.

If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer

This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association.