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24.3.12.3 Inpatient Professional Services
Initial and Subsequent Hospital Care (Nonintensive Care)
Hospital visits, observation, and discharge (procedure codes 1-99221, 1-99222, 1-99223, 1-99231, 1-99232, 1-99233, 1-99234, 1-99235, 1-99236, 1-99238, and 1-99239) are limited to one per day for the same provider.
If a hospital admission (procedure codes 1-99221, 1-99222, and 1-99223) and physician observation visit (procedure codes 1-99217, 1-99218, 1-99219, 1-99220, 1-99234, 1-99235, and 1-99236) are billed the same day by the same provider, the hospital admission will be paid and the physician observation visit will be denied.
If an initial hospital visit (procedure codes 1-99221, 1-99222, and 1-99223) following admission is billed on the same day 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 (procedure codes 1-99201, 1-99202, 1-99203, 1-99204, 1-99205, 1-99211, 1-99212, 1-99213, 1-99214, and 1-99215), outpatient consultation (procedure codes 3-99241, 3-99242, 3-99243, 3-99244, and 3-99245), the initial hospital visit will be paid and the other visits will be denied.
If a subsequent hospital visit (1-99231, 1-99232, and 1-99233) following admission is billed on the same day by the same provider as an emergency department visit (1-99281, 1-99282, 1-99283, 1-99284, and 1-99285) an office visit (procedure codes 1-99201, 1-99202, 1-99203, 1-99204, 1-99205, 1-99211, 1-99212, 1-99213, 1-99214, and 1-99215), or an outpatient consultation (procedure codes 3-99241, 3-99242, 3-99243, 3-99244, and 3-99245), the subsequent hospital visit will be paid and the other visits will be denied.
Only one initial hospital care visit may be paid to the same provider within a 30-day period regardless of diagnosis. Subsequent care visits may be considered for reimbursement during this time period.
A subsequent hospital visit (procedure codes 1-99231, 1-99232, and 1-99233) may be reimbursed on the same day to the same provider when critical care services (procedure codes 1-99291 and 1-99292) are billed.
E/M services provided in a hospital setting following a major procedure, provided by the same provider and/or in direct follow-up for post-surgical 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 bill with modifier 55. This may only be done when the surgeon submits a charge for surgical care only and there is an agreement between the physicians to split the care of the patient.
Hospital Discharge Day Management
Discharge management (procedure codes 1-99238 and 1-99239) billed on the same date of service as the admission by the same provider will be denied.
Discharge management (procedure codes 1-99238 and 1-99239) billed on the same date of service as an emergency room visit by the same provider is denied, but may be considered for reimbursement upon appeal, if provided at a separate time.
Only one discharge management service will be considered for reimbursement per day. Subsequent hospital visits billed on the same day as discharge management, by the same provider, will be denied.
Initial and/or subsequent hospital visit codes (procedure codes 1-99221, 1-99222, 1-99223, 1-99231, 1-99232, and 1-99233) billed on the same day as hospital discharge day management (procedure codes 1-99238 and 1-99239) is denied as part of another procedure billed on the same day.
Concurrent Inpatient 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 paid to providers of the same specialty for the same or related diagnoses. Diagnoses are considered to be related when there is a 3-digit match of the primary diagnosis code. Denied concurrent care may be considered on an appeal basis when accompanied by documentation of medical necessity.
Concurrent care may be considered for reimbursement to providers of different specialties when providing services for unrelated diagnoses involving different organ systems.
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