This article addresses correct reporting, to Medicare, of Inpatient Hospital Initial E&M services whose documentation does not demonstrate required CPT™ key component work for CPT codes 99221, 99222, or 99223 and cannot otherwise be coded on the basis of time related to counseling and coordination.
All E&M services reported to Medicare for payment must meet all payment requirements of the Medicare program. The most important and apparent of these requirements are proper coding, medical reasonableness and necessity, appropriate signature/authentication, and, in certain instances, compliance with “incident to” requirements. In general, any physician service that does not match the work of a defined CPT code may be reported using an appropriate unspecified CPT code. Medicare manually reviews claims and often medical records associated with services reported with unspecified CPT codes to correctly determine coverage, medical necessity and assign correct reimbursement.
Incorrect provider reporting of initial hospital E&M services (99221-99223) not uncommonly results from medical records not demonstrating key component work of any of the three initial hospital E&M CPT codes (99221-99223). For services performed on or after 10/1/2013 Novitas, upon review of a claim for such a service, will re-code the service in order to reimburse the provider for the medically reasonable and necessary work demonstrated in the record. For E&M services performed on or after 10/1/13, when appropriate to do so, Novitas will allow the payment associated with an E&M code from the subsequent hospital services group (99231-99233). Such allowance is made when the medically reasonable and necessary key component work documented matches one of the CPT codes 99231-99233.
Providers who recognize their documentation is deficient for an initial hospital service but find the documentation satisfies the medical necessity and key component work of a subsequent hospital service should report the subsequent hospital service. Providers should report medically reasonable and necessary services for which documentation does not demonstrate key component work of any defined hospital E&M service using CPT code 99499, and must be prepared to submit records to substantiate Medicare payment.
As always, providers must take care to not report for payment services that are not reasonable and necessary or for which the work defined by the CPT code used is not documented.
