Consults/Initial Hospital Care

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Posts: 47
Joined: Fri Aug 03, 2012 10:22 am

Fri Mar 22, 2019 2:27 pm

Hi. For original Medicare, I understand that the initial hospital care codes 99221-99223 should be applied for E/M services that would have been reported as consultations prior to the "big change" in 2010 when Medicare stopped recognizing the consult CPT codes. So when a specialist is asked by another provider to see a patient in the hospital and render an opinion, that's clearly a consult scenario and would be reported to Medicare as an initial (99221-99223).

However, what if a provider asks a specialist to see a patient and manage a specific aspect of the patient's care with no intent of an opinion being rendered? Now it's not an encounter that would have qualified as a consult back in the "good old days" but rather a "transfer of care". What code family does this specialist bill in this "transfer of care" scenario? Can the specialist still bill an initial hospital code, as long as their documentation supports the level? Or does the specialist have to bill a subsequent visit (99231-99233) in this scenario? I've read, re-read, and read again all the Medicare resources, MedLearns, Chapter 12, etc., but I'm not clear on what Medicare advises in this situation.

My second set of questions are specifically in regards to Nurse Practitioners. I'm being told that NPs aren't enrolled with Medicare under any specific specialty and that Medicare doesn't recognize specialties for NPs.

What if "Dr. Smith" asks a Nurse Practitioner (who bills under the same tax ID and under the same group NPI) to see a patient and render their opinion on the patient, based on the fact that the NP has taken some additional CME classes in a particular field (no official certification, just classes). Would that be classified as a "consult" by old definition and thus billable to original Medicare as an initial hospital care service (99221-99223), even if the requesting provider "Dr. Smith" was the admitting provider on the same hospital admission? Or does the Nurse Practitioner have to report a subsequent hospital visit (99231-99233) because the patient has been seen previously during the admission by a partner of the NP and the NP doesn't have a recognized different specialty from that partner in Medicare's eyes? Also, what if in that same scenario an opinion is not being sought? Would the NP report an initial (99221-99223) or a subsequent (99231-99233)? Again the request for the NP to see the patient was made by the NP's partner "Dr. Smith" who admitted the patient and bills under the same tax ID and same group NPI number as the NP.

Any help on this would be very much appreciated!
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