Medicare and Inpatient Consultations

CMS made a major blooper in their announcement about a new set of claims edits designed to keep providers from reporting new patient evaluation and management (E/M) services more frequently than allowed. But the good news is that they have fixed the edits and you should not run into any problems with them as long as you are following correct E/M coding guidelines. On May 3 CMS issued Transmittal 1231, which explained the new edits. The Transmittal listed the codes that CMS considered to be new patient services. In addition to the services that the CPT® manual designates as new patient visits, this list also included the codes for initial observation care (99218-99220) and initial hospital care (99221-99223). This meant that Medicare would not pay for these services if the patient was an established patient of the physician or practitioner (that is, a patient who received face-to-face professional services from the physician or practitioner within the past three years). Fortunately, the agency rescinded the original Transmittal and replaced it on May 31 with Transmittal 1244. Under the new Transmittal, inpatient and observation care are no longer defined as new patient services. The edits will still prevent providers from billing for two new patient office/outpatient visits within a three-year period. But they will not affect your ability to get paid for inpatient consultations, which are submitted to Medicare using the initial hospital care codes. You can read the new Transmittal on MediRegs at: by Gretchen Segado, Coding Strategies, Inc.