|
36.3.4.2 Inpatient Services
Providers may submit inpatient hospital, observation, and consultation services using the following procedure codes:
If a hospital admission (procedure codes 1-99221, 1-99222, and 1-99223) and physician observation visits (procedure codes 1-99217, 1-99218, 99219, 1-99220, 1-99234, 1-99235, and 1-99236) are submitted with the same date of service by the same provider, the hospital admission is paid and the physician observation visit is denied.
If an initial hospital visit following admission (procedure codes 1-99221, 1-99222, and 1-99223) is submitted with the same date of service by the same provider as an emergency department visit (procedure codes 1-99281, 1-99282, 1-99283, 1-99284, and 1-99285), inpatient consultation (procedure codes 3-99251, 3-99252, 3-99253, 3-99254, and 3-99255), or an office visit, outpatient consultation (procedure codes 3-99241, 3-99242, 3-99243, 3-99244, and 3-99245), the initial hospital visit is paid and the other visits are denied.
If a subsequent hospital visit following admission (procedure codes 1-99231, 1-99232, and 1-99233) is submitted with the same date of service by the same provider as an emergency department visit, an office visit, or an outpatient consultation, the subsequent hospital visit is paid and the other visits are denied.
Only one initial hospital care visit may be considered for reimbursement to the same provider within a thirty day period regardless of diagnosis. Additional hospital visits within the thirty days are considered for reimbursement as subsequent care visits.
A subsequent hospital visit (procedure codes 1-99231, 1-99232, and 1-99233) may be considered for reimbursement with the same date of service to the same provider when critical care services (procedure codes 1-99291 and 1-99292) are submitted.
E/M services provided in a hospital setting following a major procedure provided by the same provider and/or in direct follow-up for postsurgical care are included in the surgeon's global surgical fee and are denied as included in another procedure.
A physician who did not perform the surgery and provides postoperative surgical care in the time frame that is included in the global surgical fee must submit the appropriate procedure code with modifier 55. This may only be done when the surgeon submits a charge for surgical care only and there was an agreement between the physicians to split the care of the patient.
Hospital Discharge
Discharge management procedure codes 1-99238 and 1-99239 submitted with the same date of service as the admission by the same provider are denied.
Discharge management submitted with the same date of service as an emergency room visit by the same provider is denied. If the discharge management and the emergency room visit are provided at a separate time, the discharge management may be considered for reimbursement on appeal.
Only one discharge management service will be considered for reimbursement per day.
Subsequent hospital visits submitted with the same date of service as discharge management by the same provider are denied.
Initial and/or subsequent hospital visit procedure codes (1-99221, 1-99222, 1-99223, 1-99231, 1-99232, 1-99233) submitted with the same date of service as hospital discharge day management are denied as part of another procedure billed on the same day.
Nursing Facility Services
Nursing facility services may be submitted using the following procedure codes:
Providers must use initial, subsequent, and annual nursing facility assessment procedure codes when submitting claims for services in a nursing facility. Initial nursing facility assessments include all services related to an admission to the nursing facility.
Comprehensive Initial nursing facility assessments (procedure codes 1-99304, 1-99305, and 1-99306) are limited to one every 6 months.
Prolonged services in the nursing facility involving direct (face-to-face) patient contact that is beyond the usual service (procedure codes 1-99304, 1-99305, 1-99306, 1-99307. 1-99308, 1-99309, and 1-99310) may be considered for reimbursement on the same day as a nursing facility visit.
Procedure code 1-99356 should be used to report the first hour of prolonged service and will be limited to one per day.
Procedure code 1-99357 should be used to report each additional 30 minutes and will be limited to a quantity of 3 units or one and one-half hours per day.
Prolonged physician services will not be considered for reimbursement in addition to an emergency room visit submitted with the same date of service.
Procedure codes 1-99315 and 1-99316 are payable to physicians when discharging a client from a nursing home (POS 8) or specialized nursing home (POS 4). Procedure codes 1-99315 and 1-99316 are not both payable on the same day, for the same client.
Initial nursing facility assessments (procedure codes 1-99304, 1-99305, and 1-99306) or subsequent nursing facility care procedure codes (1-99307, 1-99308, 1-99309, and 1-99310) or nursing facility discharge day management (procedure codes 1-99315-1-99316) submitted with the same date of service as initial hospital care (procedure codes 1-99221, 1-99222, and 1-99223) by the same provider are denied as part of another procedure submitted on the same day.
All E/M services, irrespective of the POS, provided in conjunction with the admission by the same provider, are considered part of the initial nursing facility care when performed on the same day as the admission.
Subsequent nursing facility care E/M procedure codes (1-99307, 1-99308, 1-99309, and 1-99310) are limited to one service per day regardless of diagnosis.
Domiciliary, Rest Home, or Custodial Care
The following domiciliary and rest home care procedure codes are used to report E/M services provided to new and established patients in a facility which provides room, board, and other personal assistance services:
Established client visits submitted with the same date of service as a new client visit by the same provider will be denied as part of another procedure. Established client visits are limited to one per day regardless of diagnosis.
Home Services
Home services are those services that are provided in a private residence. A subsequent/established patient home visit submitted with the same date of service as a new patient home visit by the same provider is denied as part of another procedure submitted on the same day, regardless of the diagnosis.
The following procedure codes may be submitted for new and established patient home visits:
New patient visits are limited to one every three years.
Subsequent home E/M procedure codes are limited to one per day regardless of diagnosis.
Concurrent Care
Concurrent care exists when services are provided to a patient by more than one physician on the same day during a period of hospitalization in the inpatient hospital setting. Concurrent care is appropriate when the level of care and the documented clinical circumstances requires the skills of different specialties to successfully manage the patient in accordance with accepted standards of good medical practice.
Concurrent care will not be considered for reimbursement to providers of the same specialty for the same or related diagnoses. Diagnoses are considered related when there is a three-digit match of the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code. Denied concurrent care is considered on appeal when accompanied by documentation of medical necessity. Concurrent care is considered for reimbursement to providers of different specialties when providing services for unrelated diagnoses involving different organ systems.
Each appeal submitted for concurrent care must contain the following information:
• Documentation of the medical necessity for the physicians' services (care and treatment).
•Diagnosis and indication of the severity of the client's condition (acute or critical).
•Role of the physician in the care of the client including the name of the admitting physician.
•Specialty and/or subspecialty of each physician and any limitations of practice.
Claims appealed without clear documentation of medical necessity as described above are denied.
Important: If the attending physician requests only a consultation, the request must be clearly stated in the orders.
All concurrent care is subject to retrospective review. Documentation of medical necessity for concurrent care must be retained by the physician as required by federal law and should include, but is not limited to, documentation of:
•The orders for concurrent care or valid reasons for the request by the attending physician.
•The name of the requesting physician by the physician rendering concurrent care.
Claims Filing Deadlines
Claims submitted to TMHP by physicians for services provided during an inpatient hospital stay must be received by TMHP within 95 days of each date of service, not 95 days of the discharge date.
Reminder: Inpatient claims must indicate the facility's provider identifier in Block 32 or in the appropriate field of electronic software.
|
