cpt initial inpatient visit

Medical Billing Group

Healthcare Financial Services

How to Bill a Consultation at the Hospital (Inpatient)

Inpatient billing can be confusing.  

The first aspect to understand is that it is not based on the status of the patient. New or established status does not apply to inpatient billing codes, as they are used for an initial doctor visit, whether the practitioner has an established relationship with the patient.

Second, the old initial consultation codes (99251-99255) are no longer recognized by Medicare Part B, although many non-Medicare providers still use them if the payer doesn’t follow Medicare guidelines.  

Medicare doesn’t accept codes (99251-99255) use (99221-99223) instead

The correct inpatient consultation codes for a first evaluation are 99221-99223.  These codes are used for the inpatient History and Physical (H & P), as well as any specialty consultation (limited to one visit from each specialty).   In the past, the codes 99221-99223 were used only for the admitting physicians, and the codes 99251-99255 were designated for consulting physicians.  The consulting physician codes were dropped from Medicare guidelines due to discrepancies in paid consulting fees and the proper criteria required for those services.   The new guidelines require consulting providers also to use 99221-99223.  

When determining the appropriate level of the initial admitting code, the same requirements apply as before.  All services performed in an office and the resulting hospital admission are reflected (i.e., admission following any evaluation and management (E/M) services received by the patient in an office, emergency room, or nursing facility).  If these services are on the same date as admission, they are considered part of the initial hospital care.  

The requirements for codes 99221-99223 are more significant than for 99251-99255, and the E/M services levels must be met, taking into account the length of the visit and depth of decision making.  

No matter whether billing for Medicare or a non-Medicare provider, only one inpatient initial code can be billed for each specialty.  Additional submissions will be denied.  Subsequent hospital visits should be coded using 99231-99233 (not discussed explicitly in this writing).  

Billing CPT Codes for Inpatient Initial Hospital Visits to Medicare:  

99221:  

• 30 minutes bedside
• First inpatient encounter narrative
• Comprehensive H & P
• Low-level medical decision-making

99222:  

• 50 minutes bedside
• Moderate-level medical decision-making

99223:  

• 70 minutes bedside
• High-level medical decision-making

Billing CPT Codes for Consulting Inpatient Initial Hospital Visits Outside of Medicare Guidelines

99251:  

• Typically minor conditions
• 20 minutes bedside
• Problem-focused medical history
• Problem-focused exam
• Straightforward medical decision-making

99252:  

• Low-severity conditions
• 40 minutes bedside
• Expanded problem-focused medical history
• Expanded problem-focused exam

99253:  

• Moderate-severity conditions
• 55 minutes bedside
• Detailed medical history
• Detailed exam
• Low-complexity medical decision-making

99254:  

• Moderate-to-high-severity conditions
• 80 minutes bedside
• Comprehensive history
• Comprehensive exam
• Moderate-complexity medical decision-making

99255:  

• 110 minutes bedside  
• High-complexity medical decision-making

The required documentation for a consulting visit includes: 

• A request (verbal or written) from the referring physician  
• The specific opinion or recommendations of the consulting physician
• A written report of each service performed or ordered on the advice of the consulting physician  
• The medical expertise requested is beyond the specialty of the requesting physician  

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Initial Inpatient or Observation Care Services – CPT

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At first glance, AMA CPT coding in 2023 seems simplified in the Hospital Setting.  The distinct code set for Observation Services was deleted. The Initial Hospital Inpatient and Observation Care Services code sets merged into the 99221-99233 code set. The guidelines, however, have changed and application of the code set will depend on the patient’s “status”.

E/M Services Performed in Other Sites:

Here is the twist. In previous years, all services performed in other sites were bundled into the final destination hospital code. For example , if the patient was seen in the office and told to go to the hospital, their doc admitted them (same day), they would report only the Initial Inpatient Hospital service. In 2023, that’s now changed. Now, if you choose to report the E/M service, you can, with modifier -25 appended to the “other” E/M service code.

Consultative Services:

The catch, however, is if the initial inpatient service in the hospital is a consultative service, you will not be reporting 99221-99223, or an inpatient consultation code (99252-99255), you will instead report your consult with a SUBSEQUENT Hospital Visit Code, 99231-99233. This guidance pertains to the admitting physician (specialty/group practice).

This also holds true (according to AMA, page 23 ) “ 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. This also 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 (e.g. office or other outpatient visit or office or other outpatient consultation).”

Additionally, when reporting an initial hospital inpatient or observation care service, transition from observation level to inpatient, does not constitute a new stay.

Is there any GOOD news?

The good news is that the MDM and Time requirements are the same regardless of the patient’s “status” in the hospital (Initial Hospital Inpatient vs. Observation) when appropriately using the 99221-99233 code set.

I encourage everyone to read through the AMA definitions and guideline changes for 2023. More to come on this topic. CMS just released their CY23 final rule , and if you see Medicare patients, there is sure to be additional guidelines to layer on to this change. To get a sneak peek, turn to (page 504) to learn more about (3. Hospital Inpatient or Observation Care (CPT Codes 99218-99236). Stay tuned to the web site.

January 2023 Clarification:   Although CPT combined Inpatient Care and Observation Service codes, the original place of service still stands:

• Inpatient Services:  (POS 21)
• Observation Services: (POS 22)

If you would like additional training on these changes, please reach out to [email protected] .

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Here’s how to untangle the various categories of codes that come into play .

KENT J. MOORE

Fam Pract Manag. 2003;10(2):19-20

Family physicians must occasionally admit patients to the hospital from the office, emergency department (ED) or other sites of service. Coding admissions from these sites can be confusing. Here is what you need to know to do it correctly.

What CPT says

According to CPT, the initial hospital care codes, 99221–99223, are for “the first hospital inpatient encounter with the patient by the admitting physician.” Initial inpatient encounters by other physicians should be reported with either subsequent hospital care codes (99231–99233) or initial inpatient consultation codes (99251–99255), as appropriate.

CPT also offers the following guidance: “When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physician’s office, nursing facility) all evaluation and management (E/M) services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission [emphasis added]. The inpatient care level of service reported by the admitting physicians should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting.”

This same principle applies to the initial observation care codes, 99218–99220. Those codes are used to report “the encounter(s) by the supervising physician [emphasis added] when designated as ‘observation status.’” Observation encounters by other physicians should be coded using the office or other outpatient consultation codes, 99241–99245.

Also note that when a patient is admitted and discharged from either observation status or the hospital on the same date, CPT recommends that codes for same-day admission/discharge, 99234–99236, be used.

What Medicare and other payers say

Medicare requires that a patient be an inpatient or in observation status for a minimum of eight hours to report 99234–99236, but this is not a CPT requirement. Otherwise, Medicare policy and that of other payers generally follows the CPT guidelines with respect to hospital admissions and observation status.

For example, section 15505.1.A of the Medicare Carriers Manual states, in part, “When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.” Also, section 15505.1.F states, “Advise physicians to use the initial hospital care codes (codes 99221–99223) to report the first hospital inpatient encounter with the patient when he or she is the admitting physician.”

What it all means

The following scenarios may help you put the rules into practice:

• You see a patient in the hospital ED. During the course of that encounter, you admit the patient as an inpatient of the hospital. In this case, only an initial hospital care code, 99221–99223, should be submitted. Since the ED visit was related to the admission and occurred on the same date, you cannot separately code for that visit.

• You see a patient in your office. During the course of that encounter, you admit the patient to the hospital as an inpatient, but do not see the patient in the hospital that day. The next day, you visit the patient in the hospital for the first time. In this case, you would code an office visit (99201–99215) for services provided on the first day and an initial hospital care code (99221–99223) for services provided on the second day. Because you did not see the patient in the hospital the first day, you could not code 99221–99223 for that service since, as noted, these codes are for “the first hospital inpatient encounter with the patient by the admitting physician.” In this scenario, that encounter took place on the second day and is coded accordingly.

• You treat a patient in your office for an ear infection. That evening, you encounter the patient in the ED where she’s having severe asthma and admit her as an inpatient of the hospital. In this case, you could use an office visit code for the morning encounter and an initial hospital care code for the admission that evening. You would probably need to attach a -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the office visit code to indicate that it was unrelated to the subsequent admission. In this case, submitting different diagnosis codes would help further establish the appropriateness of coding both services.

• You see a patient in the ED. During the course of that encounter, you admit the patient to observation status at the hospital. Later that day, you determine that it is appropriate to discharge the patient to her home. In this case, you would use one of the codes for observation or inpatient care involving admission and discharge on the same date of service (i.e., 99234–99236); you would not separately code the ED visit.

It’s worth your time

Coding for hospital admissions from other sites of service can be confusing. However, since payers and CPT are generally playing by the same rules in this case, once you master the rules, appropriate reimbursement should follow.

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May 19, 2024

Initial Hospital Service Codes and Established Patients

We are having a disagreement in our coding department. Our cardiologist sees an inpatient at the hospital, but it’s a patient she knows from the office. Should she bill an initial hospital service code or a subsequent hospital service code when she sees this patient, who she knows and has seen many times?

Bill an initial hospital service, if her documentation supports it.

The initial hospital service codes are not defined as new or established. Whether the patient is known to the physician isn’t a factor in reporting the code. An initial hospital service code may be billed once per specialty group, per admission. If she sees the patient the next day, or if her same specialty partner sees the patient the next day, bill a subsequent hospital visit. Only the admitting physician may bill the discharge service.

However, CPT has a new rule in 2023 about reporting hospital services when a consultation is performed in anticipation of an admission. If your cardiologist saw the patient in consultation and sent the patient to be admitted by the hospitalist, then use a subsequent visit for the first visit. However, if that is not the case, use the initial hospital services code or inpatient consult code.

See our E/M Services Guide for additional information.

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Last revised April 8, 2024 - Betsy Nicoletti Tags: hospital inpatient/observation

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Coding Corner: Inpatient Consultations Via Telemedicine

With Sameer Sharma, MD, MBA, Society of Gynecologic Oncology (SGO) member and Director, Gynecologic Oncology at Northwest Cancer Center in Dyer, IN, and an Assistant Professor at Rush University in Chicago, IL.

Sameer Sharma, MD, MBA

Inpatient consultations via telemedicine can be used to substitute for a face-to-face encounter for initial and follow-up inpatient consultations, as well as for specialist consultations to discuss advice and recommendations physician-to-physician. These guidelines are constantly evolving during the COVID-19 public health emergency.

Initial Inpatient Consultations:

Medicare pays for reasonable and medically necessary inpatient telehealth consultation services furnished to beneficiaries in hospitals when your facility meets the following criteria for the use of a consultation code:

• The physician of record or the attending physician requests the initial inpatient telehealth consultation for their patients located in the hospital or emergency room and documents this in the patient’s medical record.
• A consultant or qualified health provider (QHP) needs to document the request for the inpatient telehealth consultation from an appropriate source and the need for an inpatient telehealth. The consultant then places this information in the patient’s medical record and lists the requesting physician.
• The visit can be performed with audio/video two-way communication; many states will also allow audio alone two-way communication.
• The consultant needs to prepare a written report of his/her findings and recommendations. Patient and QHP location should be listed in the record.
• Typically, these services are reported as telehealth services when the individual QHP is not at the same location as the beneficiary but there are no apparent limitations to the QHP location.
• The Medicare reimbursement for the consultation would include all related services furnished before, during, and after communicating with the patient via telehealth.
• Teaching Physicians: Under the so-called primary care exception at section, a teaching physician may meet the requirement to review a visit furnished by a resident remotely using audio/video real time communications technology.

These services include, but are not limited to: 

• Reviewing the patient’s diagnostic imaging and lab work
• Communicating with other physicians or family
• Documenting the visit in the patient’s chart
• Discussing the results of the telemedicine consultation
• Developing further care plans

The following codes should be used for an initial inpatient telemedicine consultation:

wRVU: work Relative Value Units

Follow-up Inpatient Consultations:

Telemedicine can be used to manage follow-up inpatient telehealth consultations  furnished to patients in hospitals. These encounters can only occur after the patient’s initial consultation.

• The visit can be performed with audio/video two-way communication; many states will also allow audio alone two-way.
• The initial inpatient consultation can be provided as either as an in-person encounter or a telemedicine visit.
• A subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days as per previous guidelines.

Follow-up inpatient telehealth consultations could include, but are not limited to, the following services: 

• Monitoring progress
• Suggesting management modifications
• Recommending a new plan of care based on changes in the patient’s status
• Coordinating care with other providers or agencies
• Communicating with other professionals
• Reviewing patient data
• Discussing the case with the patient’s family
• Completing medical records or other documentation
• Communicating the results of the consultation

The following codes should be used for a follow-up inpatient telemedicine consultation:

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Seven mistakes to avoid when billing for subsequent visits

Published in the September 2006 issue of Today’s Hospitalist

Related article: ICD-10 surprises in the hospital .

When it comes to billing for subsequent visits (CPT codes 99231-99233), many hospitalists make some relatively simple and “avoidable” mistakes.

Some errors stem from insufficient documentation and can lead to payments being denied or downcoded. Even worse, a pattern of picking the wrong subsequent visit codes may set you up for an audit.

Bill the highest subsequent visit level—99233—only for patients with a deteriorating condition. 

What to do? When billing for a subsequent hospital visit, you need to choose the appropriate level of service based on the patient’s condition and then make sure your documentation supports that choice. Here’s a list of what can go wrong “and some tips to help you avoid mistakes.

Picking the wrong code. One of the most common mistakes hospitalists make is billing for a higher level of subsequent visit than the documentation and service can support.

Bill the highest level “99233 “only for patients with a deteriorating condition, backed up by your diagnosis and documentation. If the patient is deteriorating, you need to say so clearly in your note.

A stable patient, even with multiple chronic conditions, does not qualify for a level 3 subsequent hospital visit. And if you can’t document at least one review of systems (ROS), the highest level of subsequent visit your documentation may support is a level 1 (99231).

“Clustering” subsequent visit codes. Another big mistake is using the wrong billing pattern.

Billing several level 3 (99233) visits in a row followed the next day by a discharge code, for example, could set you up for an audit. As noted above, only unstable patients meet 99233 criteria, and you wouldn’t expect those patients to be discharged the next day. (See “A scenario of subsequent visit codes” for a coding pattern that won’t set off auditor alarms.)

Skimping on history documentation. To bill a subsequent hospital visit, CPT guidelines require you to meet only two of three components: interval history, exam and decision-making.

But giving details in your history of how the patient is responding “such as “worsening,” “uncontrolled,” “stable” or “improving” “can be key indicators of the service level provided. You also need to document new complaints or symptoms to demonstrate decision-making complexity and to help support a higher level of service.

Not restating why you’re seeing the patient. You’ve seen the patient several times during her hospital stay, so you don’t need to keep documenting why you’re seeing the patient, right?

Unfortunately, that’s not the case. Even if your current note appears directly above your documentation for a previous date of service, you must state the reason why you are seeing the patient and the reason for the service to establish medical necessity. Unless the documentation for each date of service can stand alone and support the service billed, your bill for a subsequent visit may be denied.

Being too vague about follow-up. Another frequent documentation error: stating the reason for the visit is “follow-up,” without elaborating on what it is you’re following. Noting “follow-up” without documenting the patient’s specific condition could render the visit non-billable because, again, the medical necessity cannot be justified.

So don’t be vague. When following up on a patient, state “follow-up” and then the condition you’re monitoring, such as “follow-up CHF.”

Not referring specifically to a previous history. Coders or auditors can rely only on your documented notes for the date of service they are reviewing. But they can use history that you’ve previously documented “as long as you’ve specifically referenced the date the history was taken and given an update. A coder or auditor can then apply the previous history toward your level of history in the current note.

To avoid having to restate the previous note’s history, refer to that note directly. Acceptable versions include “history unchanged since [insert the date of the previous service note] or “[previous date of service] history reviewed, no changes except …”

Documenting “noted above” or “history unchanged” without specifically giving the previous note’s date won’t suffice. Another way to improve the quality of your documentation is by updating the ROS obtained when the patient was admitted, as in “ROS unchanged from [insert date of admission] admission note.”

Ignoring daily concurrent care. Concurrent care becomes a real medical necessity issue, especially when several physicians are rounding on the same patient.

Keep in mind that a subsequent hospital visit represents the services provided during an entire day–and that you can bill only one subsequent visit per day. Even if the physicians in your group bill more than one subsequent visit each day, only one subsequent visit bill will be paid.

Make sure your subsequent visit bill for any given date includes all the services rendered by providers of the same specialty within your group. Combine all visits during one calendar day and select the code that reflects the level of all the work provided.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at [email protected] . We’ll try to answer your questions in a future issue of Today’s Hospitalist.

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Inserting a central line? Tips to go beyond E/M services codes