One benefit of the new health insurance options and reforms in the Affordable Care Act starting in 2014 will be the positive impact on the creation of small businesses and sole proprietorships. The new paths to health care coverage will allow more individuals to purchase their own coverage instead of having to be employed in order to receive health care insurance.
A recent report found that the Affordable Care Act is expected to produce a sharp increase in entrepreneurship next year, according to the analysis done by the Robert Wood Johnson Foundation, the Urban Institute and Georgetown University’s Health Policy Institute.
The number of self-employed people nationally is expected to rise by 1.5 million — a relative increase of more than 11 percent — as a direct result of the health care overhaul. One major barrier to entrepreneurship in the past in the United States has been the difficulty of getting health insurance on the individual market. A pre-existing condition or disability can make it very expensive and difficult – if not impossible – to purchase health insurance as an individual. Therefore, many people remain employed in a job that is not satisfying in order to maintain health care coverage – referred to as “job lock.” If health care is more portable, more employees will have the freedom to change jobs, retire and/or start their own businesses.
According to the report and this infographic, in Illinois, there are currently 475,000 people self-employed but there are expected to be 537,000 people self-employed after the ACA is implemented – an increase of 62,000 newly self-employed or 13.1%. This increase is due to the new options for health insurance outside of the traditional employer-employee relationship and the elimination of pre-existing condition exclusions in health insurance. The ACA will create insurance marketplaces in every state where individuals and small businesses can shop for insurance and compare insurance products as well as receive financial assistance if they are low income to defray the costs of premiums and cost-sharing.
In Illinois, health care reform implementation is proceeding with the creation of the new Federal State Partnership Marketplace to open enrollment on October 1, 2013 and to start providing coverage on January 1, 2014. Illinois also recently passed Senate Bill 26 to expand Medicaid under the ACA with the potential to cover hundreds of thousands of additional low income individuals. The bill is currently awaiting the Governor’s expected signature into law. Enrollment campaigns and education and outreach will begin in earnest in the summer. More information on the Illinois effort to implement the ACA can be found at: http://www2.illinois.gov/gov/healthcarereform/Pages/default.aspx and at www.illinoishealthmatters.org.
Stephanie Altman
Health & Disability Advocates
Provider-Plan-Payer Alliance for Health - Your Input is Needed
Illinois was recently awarded a Model Design grant from the Center for Medicare & Medicaid Innovations (CMMI) for the development of a State Health Care Innovation Plan. Through these grants, CMMI is encouraging states to develop multi-payer approaches that send a consistent signal to providers and consumers incentivizing healthy behaviors, safe environments, and appropriate community supports linked to high quality care through accountable and comprehensive delivery systems. Illinois will develop its models to test over three years in the next round of funding. The grant period officially began April 1, and we must submit the comprehensive plan to CMS by September 30.
Over these six months, Illinois will develop its State Health Care Innovation Plan, which will focus on models to improve overall population health through collaboration among public health, health care, and community development sectors. The Innovation Plan will incorporate new initiatives, as well as build upon the delivery and payment system reforms already underway in Medicaid and the private sector. The planning process will require collaboration among health plans, providers, and payers to reform payment and delivery systems and the active engagement of community development and public health communities to enhance quality, improve health status and reduce overall costs.
Michael Gelder, Senior Health Policy Advisor to Governor Quinn, will lead the development of the plan in conjunction with the directors of Healthcare and Family Services, Human Services, Aging, Insurance, Professional Regulation, and Public Health. Staff workgroups will focus on delivery system/payment reform, data, and policy changes needed.
Overall, this grant is essential to achieve Governor Quinn’s goal to transform Illinois’ health care system to emphasize health, wellness, and independence. A healthy population is critical to keep health care costs affordable for businesses and families, which in turn will help Illinois attract jobs and continue to expand our economy.
Resources
Steering Committee Members
Steering Committee Presentation
State of Illinois Provider-Plan-Payer Alliance for Health
Letter from CMS Center for Medicaid Innovation Awarding Illinois the Model Design Award
CMS State Innovation Model Fact Sheet
Value of an All Payer Claims Database Webinar
Alliance Town Hall Meeting Notes - June 6, 2013
Comments
We welcome your feedback throughout the next 6 months as we develop our State Health Care Innovation Plan. Please submit your comments here and use the Town Hall Questions as a guide. Your comment and name may be made public on this site unless you indicate otherwise, with an exception for personal information or inappropriate language.
NOTE: All submissions are subject to the Freedom Of Information Act (FOIA).
[This was originally posted on the State of Illinois' Health Care Reform Website]
Illinois was recently awarded a Model Design grant from the Center for Medicare & Medicaid Innovations (CMMI) for the development of a State Health Care Innovation Plan. Through these grants, CMMI is encouraging states to develop multi-payer approaches that send a consistent signal to providers and consumers incentivizing healthy behaviors, safe environments, and appropriate community supports linked to high quality care through accountable and comprehensive delivery systems. Illinois will develop its models to test over three years in the next round of funding. The grant period officially began April 1, and we must submit the comprehensive plan to CMS by September 30.
Over these six months, Illinois will develop its State Health Care Innovation Plan, which will focus on models to improve overall population health through collaboration among public health, health care, and community development sectors. The Innovation Plan will incorporate new initiatives, as well as build upon the delivery and payment system reforms already underway in Medicaid and the private sector. The planning process will require collaboration among health plans, providers, and payers to reform payment and delivery systems and the active engagement of community development and public health communities to enhance quality, improve health status and reduce overall costs.
Michael Gelder, Senior Health Policy Advisor to Governor Quinn, will lead the development of the plan in conjunction with the directors of Healthcare and Family Services, Human Services, Aging, Insurance, Professional Regulation, and Public Health. Staff workgroups will focus on delivery system/payment reform, data, and policy changes needed.
Overall, this grant is essential to achieve Governor Quinn’s goal to transform Illinois’ health care system to emphasize health, wellness, and independence. A healthy population is critical to keep health care costs affordable for businesses and families, which in turn will help Illinois attract jobs and continue to expand our economy.
Consumer & Community Feedback Needed!
We welcome your feedback throughout the next 6 months as we develop our State Health Care Innovation Plan. Please submit your comments here (scroll down to the bottom of the page) and use the Town Hall Questions as a guide.
Your comment and name may be made public on this site unless you indicate otherwise, with an exception for personal information or inappropriate language.
NOTE: All submissions are subject to the Freedom Of Information Act (FOIA).
- See more at: http://heartlandpolicy.blogspot.com/2013/06/provider-plan-payer-alliance-for-health.html#sthash.g0hxlRcD.dpuf
Over these six months, Illinois will develop its State Health Care Innovation Plan, which will focus on models to improve overall population health through collaboration among public health, health care, and community development sectors. The Innovation Plan will incorporate new initiatives, as well as build upon the delivery and payment system reforms already underway in Medicaid and the private sector. The planning process will require collaboration among health plans, providers, and payers to reform payment and delivery systems and the active engagement of community development and public health communities to enhance quality, improve health status and reduce overall costs.
Michael Gelder, Senior Health Policy Advisor to Governor Quinn, will lead the development of the plan in conjunction with the directors of Healthcare and Family Services, Human Services, Aging, Insurance, Professional Regulation, and Public Health. Staff workgroups will focus on delivery system/payment reform, data, and policy changes needed.
Overall, this grant is essential to achieve Governor Quinn’s goal to transform Illinois’ health care system to emphasize health, wellness, and independence. A healthy population is critical to keep health care costs affordable for businesses and families, which in turn will help Illinois attract jobs and continue to expand our economy.
Consumer & Community Feedback Needed!
We welcome your feedback throughout the next 6 months as we develop our State Health Care Innovation Plan. Please submit your comments here (scroll down to the bottom of the page) and use the Town Hall Questions as a guide.
Your comment and name may be made public on this site unless you indicate otherwise, with an exception for personal information or inappropriate language.
NOTE: All submissions are subject to the Freedom Of Information Act (FOIA).
- See more at: http://heartlandpolicy.blogspot.com/2013/06/provider-plan-payer-alliance-for-health.html#sthash.g0hxlRcD.dpuf
Training for In Person Counselors and Navigators in Illinois
The State is preparing to award grants in early July to community based entities who will employ helpers to educate consumers about their new health care options under the Affordable Care Act and to assist people in enrolling in the new Medicaid expansion and Health Insurance Marketplace when open enrollment begins on October 1. These helpers will be called In Person Counselors (IPCs); however, there will also be other enrollment "helpers" called Navigators and Certified Application Counselors. The different names just refer to how the assister is funded; all of the assisters will help people choose and enroll in coverage.
In order to train these assisters, the State has partnered with the University of Illinois at Chicago School of Public Health to develop a curriculum and training program to begin by the end of July and go through the middle of September. The curriculum will consist of both online and in person learning modules. The training will be ongoing and will consist of a testing and certification process as required under state law. There will be continuing education and a backup technical assistance call center for individual questions.
In addition to the state training, IPCs and Navigators will also take a federal online Navigator training by the fall which will inform them about using the federal Marketplace portal. This is important, because all assisters in Illinois must be familiar with both the state Medicaid system as well as the federal Marketplace system since Illinois has chosen to be a partnership state and administer its health care reform programs jointly for the first year with the federal government. We are waiting on federal guidance regarding the Certified Application Counselors' training requirements.
Many other community based providers will help their clients understand and access health care coverage, even if they aren't designated "assisters" or "Navigators." These front line workers also need information on the ACA but may not need as intensive a training program as the certified assisters. There are training materials and presentations available to these organizations/ entities throughout the state including the Starting Strong Webinar Series and other events on the Illinois Health Matters events page.
Stephanie Altman
Health & Disability Advocates
An Ambitious Effort to Get Americans Covered
As the nation’s largest public health philanthropy, addressing the crisis of the uninsured is central to our mission.
Sadly, 50 million of our fellow Americans—nearly one in six of us—are uninsured. For decades, RWJF has worked to remedy the crisis of the uninsured, and this week marks an especially important milestone, as “Get Covered America” kicks off across the nation. A grassroots, consumer-driven campaign, “Get Covered America” will educate Americans about new opportunities to obtain affordable health insurance in advance of open enrollment season this fall.
RWJF provided a grant earlier this year to Enroll America to organize the “Get Covered America” campaign, and also pledged an additional challenge grant to encourage other donors to join us in this effort to reduce the staggering number of uninsured Americans.
Our support for this campaign, along with other efforts to educate people about their options, is a continuation of RWJF’s effort over many years to enroll eligible people in health insurance programs. For example, starting in 1997, RWJF made a decade-long investment of nearly $150 million to enroll children and low-income adults in coverage for which they were eligible. During this time the total number of children covered by the Children’s Health Insurance Program doubled, from 2.2 million to 4.4 million, and total Medicaid enrollment increased by 10 million people. (Find more background here.)
Significantly, RWJF did not act alone. We partnered with government officials, as well as major health stakeholders to streamline eligibility and enrollment systems to reach out and enroll eligible people. More recently, expanding participation in the Medicare Part D prescription drug benefit followed a similar model of public-private cooperation. These examples highlight an important role for philanthropy as the Affordable Care Act’s coverage provisions take effect this fall: working closely with the public and private sectors to ensure robust enrollment.
With nearly 30 million of America’s uninsured eligible for new coverage options created under the law, “Get Covered America” has undertaken an ambitious series of goals. Over the summer, campaign volunteers and staff will fan out in communities across the nation to provide people with straightforward information about these new options: their ability to shop for insurance once the state and federal marketplaces open for enrollment in October, the availability of tax credits for which they may be eligible, and for the lowest income people, eligibility for Medicaid in states that have chosen to pursue that option.
To learn more about “Get Covered America” and what you can do to help, visit www.getcoveredamerica.org.
Andrew D. Hyman
Robert Wood Johnson Foundation
(This blog was originally posted on the RWJF "Culture of Health" blog here.)
New Options for States: Facilitating Medicaid and CHIP Renewal & Enrollment in 2014
States must prepare themselves for an efficient enrollment period in order to capitalize on the upcoming changes to Medicaid eligibility under the Affordable Care Act. The Centers for Medicare & Medicaid Services (CMS)/Center for Medicaid & CHIP Services, recently released a letter that identifies enrollment strategies to help with the anticipated increase in applications. These optional strategies may facilitate enrollment while lessening administrative demands on individual states.
Here are the strategies for those states interested in adopting them:
1) Implementing the early adoption of Modified-Adjusted Gross Income, (MAGI)-based rules
Under the ACA, eligibility for all health insurance programs will be determined by MAGI methodology, which uses different income-counting procedures than current Medicaid programs. During the open enrollment period, which begins on October 1st, 2013, individuals applying for coverage in 2013 will determine their eligibility through MAGI methodology. However, individuals renewing and applying for Medicaid during that 4-month period will have their income reviewed by both current rule and MAGI methodology. States can opt to change how they determine eligibility starting October 1st in order to simplify this process.
2) Extending the Medicaid renewal period
Anyone who has a Medicaid renewal which falls in the first quarter of 2013 will also have to have their eligibility determined by both pre-MAGI and MAGI rules. Extending the renewal period will allow the states to use only the MAGI eligibility rules for simplicity.
3) Enrolling individuals into Medicaid based on Supplemental Nutrition Assistance Program, (SNAP), eligibility
The majority of non-elderly, non-disabled individuals who receive SNAP benefits are also eligible for Medicaid. Enrolling individuals in Medicaid who also receive SNAP benefits without a separate, MAGI-based income determination can help ease a state’s administrative burden. This enrollment opportunity can be implemented for a limited amount of time as states handle the demands of the increase in applications.
4) Enrolling parents into Medicaid based on their children’s Medicaid eligibility
A large number of parents with Medicaid-eligible children will also be eligible for Medicaid when changes go into effect. Enrolling parents based on their children’s eligibility can also serve as a temporary way to facilitate enrollment.
5) Adopting 12 month continuous-eligibility for parents and other adults
Many states already have 12-month continuous-eligibility for children, meaning that children are guaranteed their Medicaid coverage for a full year despite changes to their family’s income. Extending this guarantee to families will reduce the amount of “churning” between different plans, and ensure that entire families have more consistent coverage.
States that wish to implement any of these strategies must get authorization from the federal government. CMS also is encouraging states to propose any other creative strategy that will facilitate enrollment.
Illinois should consider whether some or all of these options are optimal. Implementing these strategies could lessen the administrative burden on the state, maximize enrollment of uninsured populations, maximize eligibility for low income families, and increase federal financing for health care in the state.
Stephanie Altman & Kathryn Bailey
Health & Disability Advocates
CPT® Admission Codes For Initial Inpatient & Observation Hospital H&P.
Determining the correct group of CPT® admission codes during an initial hospital encounter can be a frustrating experience for doctors and other non-physician practitioners. This lecture simplifies that complex process by having practitioners answer a series of specific questions necessary to define the correct group of care codes used in their initial hospital evaluation. Physicians use Current Procedural Terminology (CPT®) codes, part of the Healthcare Common Procedure Coding System (HCPCS), to submit claims for reimbursement. Evaluation and Management (E/M) codes are just one small portion of these codes. E/M codes are often referred to as the nonprocedural codes. These are the codes providers use to bill for such services as hospital, clinic and nursing home visits.
Once the correct group of codes has been determined, the level of service ("low, medium or high") can then be defined. This lectures will focus on choosing the correct group of codes, not the right coding level within a chosen group. For physicians and other non-physician practitioners (NPPs) who need help defining the correct level of service, I refer them to my complete collection of free and original CPT® coding lectures. After studying this lecture, readers will understand the CPT® code groups that apply to hospital inpatient and observation admissions and the questions that must be answered based on their coding scenario. I am a practicing hospitalist with over a decade of clinical experience at a large community hospital. I have written dozens of medical billing and coding lectures over the years. While some of these lectures are several years old, their information remains highly relevant today.
Listed below are all the groups of CPT® admission codes that can be can be used during an initial hospital service encounter. At first glance, some of these codes may seem out of place, but they aren't. They can and should all be used under the correct circumstance. By understanding the possible groups of codes, the questions that must be asked will make more sense. Below this list, I walk the provider through a series of questions that will help them define the correct grouping of CPT® codes to choose from. I approach the process by defining whether the provider is the attending physician or the consultant, as the choice of codes are quite variable between these two groups. As you can see from the list below, there are 12 possible groups of CPT® admission codes with 40 specific E/M codes.
This section will walk healthcare providers through the necessary questions to arrive at the correct observation CPT® admission code group. The groups available for the attending physician are critical care codes (99291 and 99292), hospital observation initial care codes (99218-99220), hospital observation subsequent care codes (99224-99226), the hospital admit and discharge same day codes (99234-99236) and the observation discharge code 99217. Refer to the decision tree flow diagram above for a big picture view of this section.
This section will walk the physician and NPP through the necessary questions to arrive at the correct inpatient CPT® admission code group. The inpatient CPT® code groups available for the consulting physician are critical care codes (99291 and 99292), hospital inpatient initial care codes (99221-99223), hospital inpatient subsequent care codes (99231-99233), and the hospital inpatient consult codes (99251-99255). Same day admission and discharge codes are reserved for the attending physician or NPP only. Remember that the inpatient hospital consultation codes have not been recognized by CMS since 2010, but may be recognized by other third party payers. Refer to the decision tree flow diagram above for a big picture view of this section.
Once the correct group of codes has been determined, the level of service ("low, medium or high") can then be defined. This lectures will focus on choosing the correct group of codes, not the right coding level within a chosen group. For physicians and other non-physician practitioners (NPPs) who need help defining the correct level of service, I refer them to my complete collection of free and original CPT® coding lectures. After studying this lecture, readers will understand the CPT® code groups that apply to hospital inpatient and observation admissions and the questions that must be answered based on their coding scenario. I am a practicing hospitalist with over a decade of clinical experience at a large community hospital. I have written dozens of medical billing and coding lectures over the years. While some of these lectures are several years old, their information remains highly relevant today.
INITIAL HOSPITAL ADMISSION CARE CODE GROUPS
Listed below are all the groups of CPT® admission codes that can be can be used during an initial hospital service encounter. At first glance, some of these codes may seem out of place, but they aren't. They can and should all be used under the correct circumstance. By understanding the possible groups of codes, the questions that must be asked will make more sense. Below this list, I walk the provider through a series of questions that will help them define the correct grouping of CPT® codes to choose from. I approach the process by defining whether the provider is the attending physician or the consultant, as the choice of codes are quite variable between these two groups. As you can see from the list below, there are 12 possible groups of CPT® admission codes with 40 specific E/M codes.- Hospital inpatient initial care: 99221, 99222, 99223
- Hospital inpatient subsequent care: 99231, 99232, 99233
- Hospital observation initial care: 99218, 99219, 99220
- Hospital observation subsequent care: 99224, 99225, 99226
- Hospital inpatient initial consult care: 99251, 99252, 99253, 99254, 99255
- Hospital admit/discharge same date care: 99234, 99235, 99236
- Outpatient established office care 99211, 99212, 99213, 99214, 99215
- Outpatient, new to office care: 99201, 99202, 99203, 99204, 99205
- Outpatient consult care: 99241, 99242, 99243, 99244, 99245
- Critical care: 99291 and 99292.
- Hospital inpatient discharge codes: 99238, 99239 (rarely)
- Hospital observation discharge code: 99217 (rarely)
Once the provider understands how these codes are grouped together, picking the correct set of codes is simple if the right questions are asked. These questions are detailed below. Just below the questions, I have created a flow chart decision tree analysis tool to help the reader visualize the pathway to the correct group of CPT® admission codes. As you continue to read, refer to this flow chart for quick reference.
- Does my patient meet criteria for billing critical care?
- Am I the attending physician or am I a consultant on the case?
- Does my documentation support the code I am supposed to use?
- Does the code I chose appropriately describe the level of service provided?
- Did my admission face-to-face encounter and discharge face-to-face encounter occur on the same date?
- Was my discharge encounter more or less than eight hours after the original face-to-face encounter on the same date or did I only provide one face-to-face encounter for admission and discharge?
- Did I provide one or two face-to-face encounters on the same date admit/discharge?
- Have I seen the patient in the last three years?
- Has anyone in my group of the same specialty seen the patient in the last three years?
- Does the patient have Medicare or other insurance that does not recognize consultation codes?
"Medicare Part B adjudicates physician services based on the calendar date of the service. In the above situation, the physician would submit the combination hospital inpatient/discharge services (99234-99236). In the Medicare Part B environment, the time of an "admission" to the hospital is not a physician payment issue. The physician service begins when he/she actually see the patient and performs the work for which Medicare may make payment. The "admission" time and date are necessary for the hospital billing, but not for the physician billing."
Here is a direct link to the image below on Photobucket. The original source file appears to be broken. Make sure to click on the magnifying glass in the lower right hand corner of the image for the full size view.
ATTENDING PHYSICIAN
INPATIENT
This section will walk the physician and NPP through the necessary questions to arrive at the correct inpatient CPT® admission code group. The groups available for the attending physician are critical care codes (99291 and 99292), hospital inpatient initial care codes (99221-99223), hospital inpatient subsequent care codes (99231-99233), hospital admit and discharge same day codes (99234-99236) and very rarely the hospital discharge codes (99238 and 99239). Refer to the decision tree flow diagram above for a big picture view of this section.
- Does my documentation meet the threshold for critical care?
- YES: Choose critical care codes 99291 and or 99292. If your admission encounter meets the threshold for critical care, you have found your correct admission CPT® code group. Critical care codes can be used on admission and on followup hospital care. There is no limit to the number of times they can be used on any one patient in the hospital, but documentation should support their use. Critical care codes can be used at any site of care. Patients do not have to be in the ICU to use these codes. Likewise, being in the ICU does not mean a patient qualifies for using critical care codes either.
- NO: Go to question #2.
- Does my documentation support use of hospital inpatient initial care codes (99221, 99222, 99223)?
- YES: Go to question #3.
- NO: Choose from the inpatient hospital subsequent care code group (99231, 99232, 99233). These codes are used as initial care codes when documentation does not support the use of the initial care codes (99221-99223) or the admit/discharge same day codes (99234-99236). This is allowable because the Centers For Medicare & Medicaid Services (CMS) says they are. CMS has previously stated "in all cases, physicians will bill the available code that most appropriately describes the level of the services provided". Another document supports this concept as well. In a Q&A resource from one Medicare carrier, they answered: "If the documentation for the initial visit does not support one of the initial inpatient procedure codes, CMS has instructed contractors to not find fault with the physician billing a subsequent care procedure instead." I often use subsequent care codes as my initial hospital service when evaluating routine post operative consults for medical management when an H&P has been provided by the primary care physician before surgery. Technically, I could choose to provide a full H&P that would rise to the level of an initial inpatient procedure code, but I often choose not to spend the additional time required for initial care codes. If documentation does not support use of these inpatient subsequent care codes, I recommend getting intense coding education as you will have provided your service for free. There are no alternative codes to consider.
- Was my face-to-face discharge encounter date different than my face-to-face admission calendar date?
- YES: Choose from the inpatient hospital initial care codes 99221-99223. These are the "H&P" codes. This group of CPT® codes will be used for the majority of your admissions.
- NO, my admission and discharge face-to-face encounters or encounter (if the patient was seen just one time) occurred on the same calendar date. Go to question #4:
- Did I discharge the patient less than 8 hours from my first face-to-face encounter (or provide only one face-to-face encounter for admission and discharge)?
- YES: Choose from the inpatient hospital initial care codes 99221-99223. Some resources suggest the physician can instead choose the discharge code 99238 or 99239 if only one face-to-face encounter was provided and the service was consistent with a discharge encounter. There is some discrepancy in resources from CMS and Medicare carriers in this scenario. Regardless, physicians who admit and discharge patients less than 8 hours between their admission and discharge face-to-face encounter or if they only provided one face-to-face encounter should not submit same day admit and discharge codes 99234-99236. Should they submit for the admission (99221-99223) or the discharge (99238 or 99239) code? Read the discussion below:
- CMS discussed this in section 30.6.9.1 of of change request 6740 of transmittal 1875 from December 14th, 2009. They say to use the initial encounter admission codes.
- "When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT® codes 99238 or 99239, shall not be reported for this scenario." That sounds pretty clear to me.
- However, this Medicare carrier says you could consider billing for the discharge instead. In question 2 at this Medicare carrier resource they say "The medical record documentation determines the appropriate procedure code. The physician could bill an initial inpatient visit or a discharge management summary based on the service documented. The combination admit and discharge procedures codes are not appropriate since the patient was an inpatient for less than 8 hours."
- Discharge codes 99238 and 99239 are only supposed to be used on dates different than the date of admission. It says so in the AMA definition of these CPT codes. So there may be a discrepancy in how the AMA defines the code and what CMS allows. This is not precedent. It has happened before (such as the prolonged service codes). There appears to be contradictory information between CMS documents and the Medicare carrier resource above. Billing a 99238 or 99239 on the same date of the physician's first face-to-face encounter is contradictory to the AMA definition of these discharge codes. My recommendation is to provide an intensity of service that meets the criteria for the inpatient admission codes if only one face face-to-face encounter or two face-to-face encounters were provided less than 8 hours apart on the same calendar date and bill 99221-99223 if documentation supports it. If documentation does not support these codes, go to question #2.
- NO, my patient was discharged greater than 8 hour from admission on the same calendar date: Go to question #5.
- Did I or my partners in combination with me provide two face-to-face encounters at least eight hours apart on the same calendar date?
- YES: Choose from the hospital admit and discharge same day inpatient or observation care codes 99234-99236. This is a bundled care code. If two physicians from the same group and specialty each provide one of the face-to-face encounters, only one provider should submit the code from the care group 99234-99236. Traditionally, the physician or other NPP who provided the admission encounter would get credit because of the higher intensity of service provided during the initial admission H&P service. I have provided a thorough review of the admit and discharge same day CPT® codes at this link. If you don't have two documented face-to-face encounters separated by 8 hours, then go back to question #4.
- NO, two face-to-face encounters were not provided: Choose from the inpatient hospital initial care codes 99221-99223. As I stated above, I do believe the discharge codes 99238 or 99239 apply. These codes should apply to discharge services on a date different from the admission face-to-face encounter.
OBSERVATION
This section will walk healthcare providers through the necessary questions to arrive at the correct observation CPT® admission code group. The groups available for the attending physician are critical care codes (99291 and 99292), hospital observation initial care codes (99218-99220), hospital observation subsequent care codes (99224-99226), the hospital admit and discharge same day codes (99234-99236) and the observation discharge code 99217. Refer to the decision tree flow diagram above for a big picture view of this section.
- Does my documentation meet the threshold for critical care?
- YES: Choose critical care codes 99291 and or 99292. See the discussion above on question #1.
- NO: Go to question #2.
- Does my documentation support use of hospital observation initial care codes (99218, 99219, 99220)?
- YES: Go to question #3.
- NO: Choose from the hospital observation subsequent care code group (99224, 99225, 99226). See the discussion in question #2 above to understand why this group of codes is appropriate.
- Was my face-to-face discharge encounter date different than my face-to-face admission calendar date?
- YES: Choose from the observation hospital initial care codes 99218-99220 .
- NO, my admission and discharge face-to-face encounters or encounter (if the patient was seen just one time) occurred on the same calendar date.
- Did I discharge the patient less than 8 hours from my first face-to-face encounter (or provide only one face-to-face encounter for admission and discharge)?
- YES: Choose from the observation hospital initial care codes 99218-99220. Physicians who admit and discharge patients who spend less than 8 hours in the hospital should not submit same day admit discharge codes 99234-99236. I discussed the use of the options for using the discharge code (99217 in this case) above in the attending section (under question #4). I do not recommend it. See that discussion to better understand the reasoning.
- NO, my patient was discharged greater than 8 hours from the face-to-face admission encounter on the same calendar date: Go to question #5.
- Did I or my partners in combination with me provide two face-to-face encounters at least eight hours apart on the same calendar date?
- YES: Choose from the hospital admit and discharge same day inpatient or observation care codes 99234-99236. See the discussion above at question #5.
- NO, two face-to-face encounters were not provided: Choose from the observation hospital initial care codes 99218-99220. Again, I do not recommend billing observation CPT® discharge code 99217. This code should only apply for discharge services on dates different than the admission face-to-face encounter.
CONSULTING PHYSICIAN
INPATIENT
This section will walk the physician and NPP through the necessary questions to arrive at the correct inpatient CPT® admission code group. The inpatient CPT® code groups available for the consulting physician are critical care codes (99291 and 99292), hospital inpatient initial care codes (99221-99223), hospital inpatient subsequent care codes (99231-99233), and the hospital inpatient consult codes (99251-99255). Same day admission and discharge codes are reserved for the attending physician or NPP only. Remember that the inpatient hospital consultation codes have not been recognized by CMS since 2010, but may be recognized by other third party payers. Refer to the decision tree flow diagram above for a big picture view of this section.
- Does my documentation meet the threshold for critical care?
- YES: Choose critical care codes 99291 and or 99292.
- NO: Go to question #2.
- Does my patient have Medicare?
- YES: Go to question #3. Medicare no longer recognizes hospital inpatient consultation codes.
- NO: Go to question #4.
- Does my documentation support use of hospital inpatient initial care codes (99221, 99223, 99223)?
- YES: Choose from the inpatient hospital initial care codes 99221-99223.
- NO: Choose from the inpatient hospital subsequent care codes 99231-99233. These codes are used as initial care codes when documentation does not support the use of the initial care codes (99221-99223). I have provided reference to CMS opinion of this situation in question #2 in the inpatient attending discussion.
- Does my patient's non-Medicare insurance recognize the inpatient CPT® consult code group 99251-99255?
- YES: Go to question #5.
- NO: Go to question #3.
- I DON'T KNOW: Find out. When you find out, choose yes or no in question #4.
- Does my documentation support the use of hospital inpatient consult care codes 99251-99255?
- YES: Choose from the inpatient hospital consult care codes 99251-99255.
- NO: Choose from the inpatient hospital subsequent care codes 99231-99233. This is the only alternative group of codes from which to choose from. As stated above, the physician should bill the code that most appropriately describes the level of service provided. If the documentation does not support the inpatient hospital consult codes, then the subsequent care codes should be used instead. If documentation does not support the use of the subsequent care codes, I recommend the physician seek intensive coding education as no other codes are available. That means they provided their service here for free.
OBSERVATION
This section will walk providers through the necessary questions to arrive at the correct observation CPT® admission code group. Being a consultant on an observation case is the most difficult of the coding scenarios I have detailed above. The observation CPT® code groups available for the consulting physician are critical care codes (99291 and 99292), new patient office or other outpatient visit care codes (99201-99205), established patient office or other outpatient visit care codes (99211-99215), and the office or other outpatient consultation codes (99241-99245). Remember, office or outpatient consultation codes are no longer recognized by CMS but may be recognized by other third party payers. Refer to the decision tree flow diagram above for a big picture view of this section.
- Does my documentation meet the threshold for critical care?
- YES: Choose critical care codes 99291 and or 99292.
- NO: Go to question #2.
- Does my patient have Medicare?
- YES: Go to question #3. Medicare no longer recognizes outpatient and office consult codes.
- NO: Go to question #7.
- Have I seen the patient at any time in the last three years?
- YES: Go to question #5.
- NO: Go to question #4.
- Have any of my partners in my same group and same specialty seen the patient at anytime in the last three years?
- YES: Go to question #5.
- NO: Go to question #6.
- Does my documentation support the use of established patient office or other outpatient visit care codes 99211-99215?
- YES: Choose from the established patient office or other outpatient visit codes 99211-99215.
- NO: Nothing can be billed. I recommend the physician or other NPP obtain help with their coding skills. You just saw the patient for free.
- Does my documentation support the use of the new patient office or other outpatient visit care codes 99201-99205?
- YES: Choose from the new patient office or other outpatient visit care codes (99201-99205).
- NO: Go to question #5.
- Does my patient's non-Medicare insurance recognize the office or other outpatient consultation codes 99241-99245?
- YES: Go to question #8.
- NO: Go to question #3.
- I DON'T KNOW: Find out. Once you find out, choose yes or no in this question.
- Does my documentation support the use of the office or other outpatient consultation codes 99241-99245?
- YES: Choose from the office or other outpatient consultation codes 99241-99245.
- NO: Go to question #5.
In this lecture, I have touched on the majority of situations the attending or consulting physician will find themselves in when trying to decide which CPT® admission code group to utilize. I have provided a walk through series of questions based on whether the physician or NPP is filling the role of attending or consultant in the inpatient or observation hospital setting. It is my hope readers bookmark this lecture for quick reference when they have questions about which admission code to choose on their initial evaluation. Of course, there are other issues to consider as well, such as seeing patients with non-billing resident or billing and non-billing NPPs. I do not currently have any resources on billing shared services in the academic environment using shared services with residents. I do, however, have a detailed review of coding in shared services situations when patients are seen in conjunction with non-physician practitioners (billing and non-billing). I cover numerous scenarios for inpatient and observation situations that involve care before and after the midnight hour.
And finally, here is a Happy Hospitalist original flow diagram detailing all the actual thought processes that go into deciding which CPT® admission codes are correct for the initial hospital H&P encounter. I think it accurately details the quirks, irritations and internal emotional distress many providers experience during the process. This diagram is copy write protected by The Happy Hospitalist. If you wish to forward it on to your colleagues, I ask that you provide reference back to this lecture post. This is the mother of all CPT® admission decision diagrams. I have framed the image due to its very large size. You can also view it directly at the full screen view here. Make sure to click the magnifying glass image in the bottom right corner of the image to expand the view on Photobucket. The original source file site appears to be broken, so use this Photobucket link to view.
If you've decided you don't want to click through to view the diagram, here's a screen shot below that might change your mind. It's funny people. Trust me.
Once you've determined the correct group of CPT® admission codes, The Happy Hospitalist has laminated hospital and clinic bedside pocket E/M reference cards available to help the clinician determine the correct level of service within the code group. All purchase proceeds are donated to charity to help make this world a better place. Click on your desired option below and stay compliant with all your daily E/M coding adventures.
LINK TO HOSPITALIST POCKET CODING CARD POST
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Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.
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