(Medicare Claims Processing Manual)

30.6.9.2 - Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management (Codes 99231 - 99239)                                                                                                      (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A. Subsequent Hospital Inpatient or Observation Care Visits During the Global Surgery Period   (Refer to 40 -40.4 on global surgery)   The Medicare physician fee schedule payment amount for surgical procedures includes all services (e.g., evaluation and management visits) that are part of the global surgery payment; therefore, A/B MACs (B) shall not pay more than that amount when a bill is fragmented for staged procedures.   B. Hospital Inpatient or Observation Discharge Day Management Service   Hospital Inpatient or Observation Discharge Day Management Services, CPT code 99238 or 99239 is a face -to-face evaluation and management (E/M) service between the attending physician and the patient.  The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date.  Only one hospital inpatient or observation discharge day management service is payable per patient per hospital stay.   Only the attending physician of record reports the discharge day management service.  Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range 99231 -  99233) for a final inpatient hospital visit; practitioners furnishing additional observation care services bill t he appropriate office/outpatient code, per section 30.6.8.B.   C. Subsequent Hospital Inpatient or Observation Visit and Discharge Management on Same Day  Pay only the hospital inpatient or observation discharge management code on the day of discharge (unless it is also the day of admission, in which case, refer to 30.6.9.1 C for the policy on Hospital Inpatient or Observation Care Services (Including Admis sion and Discharge Services CPT Codes 99234 -  99236).  A/B MACs (B) do not pay both a subsequent hospital inpatient or observation care visit in addition to hospital inpatient or observation discharge day management service on the same day by the same phys ician.  Instruct physicians that they may not bill for both a hospital inpatient or observation care visit and hospital inpatient or observation discharge management for the same date of service.   D. Hospital Inpatient or Observation Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day   A/B MACs (B) pay the hospital inpatient or observation discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.   If a surgeon is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission and care w ith a modifier  -24 and provides documentation that the service is unrelated to the surgery (e.g., return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge from the hospital for cholecystectomy).   A/B MACs (B) do not pay for a nursing facility admission by a surgeon in the postoperative period of a procedure with a global surgical period if the patients admission to the nursing facility is to receive post operative care related to the surgery (e.g. , admission to a nursing facility to receive physical therapy following a hip replacement).  Payment for the nursing facility admission and subsequent nursing facility services are included in the global fee and cannot be paid separately.   E. Hospital Inpatient or Observation Discharge Management and Death Pronouncement   Only the physician who personally performs the pronouncement of death shall bill for the face -to-face Hospital Inpatient or Observation Discharge Day Management Service, CPT code 99238 or 99239.  The date of the pronouncement shall reflect the calendar dat e of service on the day it was performed even if the paperwork is delayed to a subsequent date.   30.6.10 - Consultation Services  (Rev.  2282, Issued: 08- 26-11, Effective: 01 -01-11, Implementation: 11- 28-11)  Consultation Services versus Other Evaluation and Management (E/M) Visits   Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment.  Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed.   In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221 -99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304 -99306), or subsequent nursing facility care code (99307- 99310) that reflects the services the physician or practitioner furnished .  Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.  A/B MACs (B) shall not find fault in cases wh ere the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.  Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M s ervice that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service.  Reporting code 99499 requires submission of medical records and A/B MAC (B) manual medical review  of the service prior to payment.  CMS expects reporting under these circumstances to be unusual.  The principal physician of record is identified in Medicare as the physician who oversees the patients care from other physicians who may be furnishing specialty care.  The principal physician of record shall append modifier  -AI (Principal Physician of Record), in addition to the E/M code. Follow -up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.   In the CAH setting, those CAHs that use method II shall bill the appropriate new or established visit code for those physician and non- physician practitioners who have reassigned their billing rights, depending on the relationship status between the physic ian and patient.   In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall use the CPT codes (99201 -  99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician.  All physicians and qualified nonphysician practitioners shall follow the E/M documentation guidelines for all E/M services.  These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer.   30.6.11 - Emergency Department Visits (Codes 99281 - 99288)  (Rev. 1875, Issued: 12- 14-09, Effective: 01 -01-10, Implementation: 01- 04-10)  A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department   Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.  B. Use of Emergency Department Codes In Office   Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. The emergency department is defined as an organized hospital -based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention.  C. Use of Emergency Department Codes to Bill Nonemergency Services   Services in the emergency department may not be emergencies. However the codes (99281 - 99288) are payable if the described services are provided.   However, if the physician asks the patient to meet him or her in the emergency department as an alternative to the physicians office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate offi ce/outpatient visit codes. Normally a lower level emergency department code would be reported for a nonemergency condition.  D. Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission   Emergency department visit provided on the same day as a comprehensive nursing facility assessment are not paid. Payment for evaluation and management services on the same date provided in sites other than the nursing facility are included in the payment f or initial nursing facility care when performed on the same date as the nursing facility admission.   E. Physician Billing for Emergency Department Services Provided to Patient by Both Patients Personal Physician and Emergency Department Physician   If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether  the patient should be admitted to the hospital or be sent home, the physicians should bill as follows:    If the patient is admitted to the hospital by the patients personal physician, then the patients regular physician should bill only the appropriate level of the initial hospital care (codes 99221 -  99223) because all evaluation and management services pr ovided 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.  The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes.    If the ED physician, based on the advice of the patients personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service.  The patients personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department.  If the patients personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patients personal physician may not bill.  F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting   If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code.  If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.   30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes 99291  - 99292)  (Rev. 11288; Issued:0 3- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  30.6.12.1  Definition  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  For payment under the Medicare Physician Fee Schedule (PFS), Medicare adopts the definition of critical care services in the CPT Codebook, and the CPT listing of bundled services, unless otherwise specified.  This includes t he CPT prefatory language stating that critical care is the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminen t or life -threatening deterioration of the patients condition.  It involves high complexity decision- making to treat single or multiple vital organ system failure and/or to prevent further life -threatening deterioration of the patients condition.   Bundled services that are included by CPT in critical care services and therefore not separately payable include interpretation of cardiac output measurements, chest X rays, pulse oximetry, blood gases and collection and interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data), gastric intubation, temporary transcutaneous pacing, ventilator management, and vascular access procedures.  As a result, these codes are not separately billable by a practitioner during the time -period when the practitioner is providing critical care for a given patient.  T ime spent performing separately reportable procedures or services should be reported separately and should not be included in the time reported as critical care time.   Because critical care services are delivered by a physician(s) or QHP(s), critical care may be reported by physicians and other practitioners who are qualified by education, training, licensure/regulation (when applicable), facility privileging (when appli cable), and the applicable Medicare benefit category to perform critical care services and independently report them, referred to in this manual section as physicians and non- physician practitioners (NPPs).