pqri measure coding and reporting principles - Indiana Academy of ...

the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the
initial hospital admission. Carriers pay the office visit as billed and the Level 1 initial hospital care code.
F. Initial Hospital Care Visits by Two Different M.D.s or D.O.s When They Are Involved in Same
Admission
Physicians 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.
Carriers consider only one M.D. or D.O. to be the admitting physician and permit only the admitting
physician to use the initial hospital care codes. Physicians that participate in the care of a patient but are
not the admitting physician of record should bill the inpatient evaluation and management services codes
that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient
consultation).
G. Initial Hospital Care and Nursing Facility Visit on Same Day
Carriers pay only the initial hospital care code if the patient is admitted to a hospital following a nursing
facility visit on the same date by the same physician. Payment for the initial hospital care service includes
all work performed by the physician in all sites of service on that date.
Subsequent Hospital Visit and Hospital Discharge Management
Medicare Claims Processing Manual Chapter 12 §30.6.9.2 (Codes 99231-99239) (Rev. 1, 10-01-03)
A. Subsequent Hospital Visit and Discharge Management on Same Day
Carriers only pay the hospital discharge management code on the day of discharge (unless it is also the
day of admission, in which case, the admission service and not the discharge management service is
billed). Carriers do not pay both a subsequent hospital visit in addition to hospital discharge day
management service on the same day by the same physician.
B. Hospital 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
Carriers pay the hospital 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.
Face-to-Face Visit Required for Discharge Services
All E/M services except where specifically stated (e.g., care plan oversight which is a monthly summary)
require a face-to-face interaction between the physician and the patient. The discharge service is a face-toface
E/M service.
Carriers monitoring for the time period April 2004 through March 2005, the date of service (DOS) of
seven (7) to fifteen (15) percent of the discharge service codes (99238, 99239, 99315, and 99316)
submitted were the same as the date of death of the patient.
CMS provided the following information regarding the use of time-based codes:
The discharge day management service by definition does not have the elements of history,
physical examination, and medical decision-making, as many of the other E/M codes have. The
provider uses this final visit as appropriate, for a final examination, discussion of problems,
instructions, and follow-up. A provider may choose to bill a subsequent hospital visit service code
instead of a discharge service code. The provider is not required to bill a discharge day
management service.
The discharge day management service is a time-based service. In order to support services that
require greater than 30 minutes (codes 99239 and 99316) the total time spent must be
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*All CPT Codes, Descriptions, and Two-Digit Modifiers
Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01
Copyright 2007 Newby Consulting, Inc.