Medical necessity of inpatient care is determined by a combination of factors including the physician’s assessment of the patient’s history and physical, commonly referred to as the H&P, as well as the review of specific risk factors that are characteristic to the patient’s condition at the time of admission.

The hospital’s utilization review (UR) plan committee consists of the only lawfully authorized practitioners who can change a patient’s status from inpatient to outpatient. This decision must be made prior to the patient’s discharge and would determine if the hospital itself will submit an inpatient or outpatient claim to the beneficiary’s insurance. The admitting physician must always be consulted by the UR committee if determination is made that medical necessity was not in fact met for their patient’s hospital stay. Just as well, the admitting physician’s claims should follow-suit with the hospital’s claim, whether inpatient or outpatient.

In accordance to the American Medical Association, inpatient admission CPT codes are as follows: 99221, 99222, and 99223. Only one practitioner will be reimbursed for the patient’s hospital admission service. An AI modifier is to be appended to the inpatient admission CPT code for the services provided by the admitting physician. Only one physician can be the patient’s admitting physician.

Additional providers billing services provided on the same date as the admitting physician’s hospital admission should report inpatient Evaluation and Management (EM) service codes based of their own medical necessity, individual time spent with the patient, and their specific services provided to the patient. However, if additional outpatient services were provided on the same day of the admission, those reimbursements will bundle with the patient’s initial inpatient hospital care.

Subsequent inpatient hospital care services should be reported under code 99231, 99232, or 99233. These services should be submitted to report subsequent inpatient services per day. If two providers of the same specialty care for a patient for the same diagnosis on the same day, both providers’ services are submitted under a single-combined, subsequent care code. Therefore, if two providers amid two different specialties have cared for the patient for different reasons, or different diagnoses, on the same date of service, both providers may submit an individual, subsequent care code.

As the patient is deemed fit for discharge, inpatient hospital care discharge codes are reported via 99238 or 99239. One discharge code should be reported per hospital stay and by the attending physician. The services should be reported with the date services were actually rendered, despite if the patient was discharged on a later date (not as common of an occurrence). If other providers care for the same patient on the same date the attending physician’s discharge services, subsequent hospital care codes should be reported for their additional services.

Stay tuned for our next blog article outlining the specific differences among inpatient hospital care codes, Coding Inpatient Hospital Care.

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