Home Coding How hospitalists can bill for consults and admissions

How hospitalists can bill for consults and admissions

CD-9 Billing codes and modifiers for consults, observations, and admissions

October 2010

Published in the October 2010 issue of Today’s Hospitalist

MEDICARE’S DECISION to eliminate consultation codes beginning this year has left readers with many questions on how to bill for consults and admissions. In addition, the discussion about observation status in my July column (“Making sure your patients stay admitted“) has led to further questions. Here’s some clarification on those points.


Keep up with the latest coding questions: Billing two visits a day for one patient? Not so fast, March 2017.



Consult codes and modifiers
When I’m acting as a consultant for a Medicare patient, what codes do I use? For example, say I do an initial consult on a surgical patient. Should I use an initial hospital care code (99221-99223) without the ‘Al modifier? And do I continue using an initial code for subsequent visits?

Medicare’s term for the admitting physician is “principal physician of record,” and only that physician should use the ‘Al modifier to signify charges for that principal role. I’m assuming that the surgeon remains the principal physician in the example you mentioned, so use an admission code (99221-99223) without the modifier for your initial visit. Then use subsequent visit codes “again, with no modifier “for follow-up visits.


Related article: Billing for Time – Getting it Right


I understand that for Medicare patients, I use the -AI modifier with an initial hospital care code (99221- 99223) when I admit a patient under my service. But do I continue to use that modifier for subsequent visits and discharges (99231-99233, 99238-99239)?

No, don’t use the -AI modifier with a subsequent visit or discharge code. Use it only with an initial hospital care code (99221-99223) for the first visit if you’re the principal physician of record.

Medical residents see all of our patients. Should we continue to use the -GC modifier (indicating services performed by a resident under the direction of a teaching physician) in addition to the -AI modifier for an admission when we are the admitting physician?

Yes, use both modifiers.

I’m a hospitalist who has an individual contract with a hospital, as do several other hospitalists working here; we’re not in the same group, although we hand off patients to each other. When I come on service, I pick up patients from a doctor going off service. All these patients are new to me, so my first visit takes a lot of time. May I bill an initial hospital care code (99221-99223) for these first-day encounters?

For non-Medicare patients, only the admitting physician can bill an initial visit code (99221-99223). Because you are not the admitting physician, bill a subsequent visit code (99231-99233) instead.

For Medicare patients, the Centers for Medicare and Medicaid Services ruled that as of Jan. 1, 2010, admission codes (99221-99223) should be used for either the initial visit by a provider or the first visit by providers of the same group. Because you’re not part of a group, you can bill the admission code for your initial visit. If you were the principal physician of record, you’d indicate that with the -AI modifier.

Observation status
Patients who have ED observation status (they’re not admitted or placed in hospital observation status) are being seen by a hospitalist and discharged. How should the hospitalist bill that visit: as a discharge, a consult or something else?

Because the patient doesn’t have “hospital” observation status, the emergency department is the place of service. There is no code for an emergency department discharge, so which code to use depends on whether the patient is covered by Medicare and whether you were asked to render an opinion on a specific issue.

If your opinion was sought for a non-Medicare patient, bill an outpatient consultation code (99241- 99245). If you were asked to treat a non-Medicare patient, use the office or other outpatient service codes (99201-99215).

For Medicare patients, on the other hand, because consult codes have now been eliminated, Medicare is directing you to use the emergency department visit codes (99281-99285), whether you were asked to render an opinion or not.

Inpatient vs. observation
I have a question about your July column and billing for physician services when a patient’s status changes in the middle of a hospital stay. If I understand you correctly, when a patient is downgraded to observation from inpatient status, the initial admission day to observation should be reported with an outpatient service code (99201-99215). But another recent article suggested the opposite: reporting the whole stay as observation. How should I reconcile those two opinions?

Medicare has no provision to allow physician observation services to be retrospectively ordered. Therefore, when a patient’s status doesn’t meet inpatient criteria and is changed, you would have to use outpatient service codes (99201-99215) for the downgraded portion of the patient’s stay until you place an order for observation status.

If that order takes place during the first day that the patient is downgraded, you could bill that day using observation codes. If, however, a physician doesn’t order observation status until the second calendar day of a downgraded stay, you’d have to bill the first day with outpatient service codes (99201-99215) and then the second day with observation codes (99218- 99220, 99234-99236).

Medicare does, however, allow hospitals to bill for observation services when a patient’s status changes. In such a situation, hospitals would use condition code 44 on the hospital claim form. I know the article you’re referring to, and it mentions the “Medicare Claims Processing Manual,” Chapter 1, Section 50 “which is the section for condition code 44.

While the article seems to suggest that this code applies to physician services, that is incorrect. As for how to bill physician services in this case, we can only hope that Medicare will clarify this issue for physicians as it has for hospital billing. In the meantime, physicians should use outpatient service codes (99201-99215) to bill for their services if they don’t have an observation order.

Say a patient is changed from observation to inpatient status and we don’t choose to do a full admit the next day. We instead bill a subsequent visit code (99231-99233). Do we bill the initial admission day as observation?

Yes, bill the first calendar day while the patient was in observation with an observation code (99218-99220). If you didn’t do a comprehensive history and physical on the day the patient’s status changed to inpatient admission, bill that day with a subsequent visit code (99231-99233), not an initial hospital care code (99221-99223).

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