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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.56 Physician Evaluation and Management (E/M) Services : 9.2.56.6 Inpatient Hospital Services

9.2.56.6
Hospital visits are limited to one per day for the same provider.
Only one initial hospital care visit may be reimbursed to the same provider within a 30-day period for the same diagnosis. Additional initial hospital visits with the same diagnosis within a 30-day period will be denied.
A hospital care visit submitted by the same provider for the same client within three days of a new patient office, home, nursing facility, or skilled nursing facility (SNF) visit, for the same or for a similar diagnosis must be submitted as a subsequent care visit.
Refer to:
Subsection 9.2.69.6, “Global Fees,” in this handbook for more information about global services.
9.2.56.6.1
Inpatient hospital visits must be submitted using procedure codes 99221, 99222, 99223, 99231, 99232, and 99233.
If a subsequent hospital visit (procedure code 99231, 99232, or 99233) following admission is billed by the same provider with the same date of service as any of the following emergency department visits, office visits, or outpatient consultations, the subsequent hospital visit may be reimbursed and the other visits will be denied:
 
Only one initial hospital care visit may be reimbursed to the same provider within a 30-day period for the same diagnosis. Additional initial hospital visits with the same diagnosis within a 30-day period will be denied.
A subsequent hospital visit (procedure code 99231, 99232, or 99233) may be reimbursed to the same provider when performed on the same day as critical care services (procedure codes 99291 and 99292).
E/M services provided in a hospital setting following a major procedure and provided by the same provider 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.
Refer to:
Subsection 9.2.44, “Newborn Services,” in this handbook for information about newborn services.
9.2.56.6.2
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 require the skills of different specialties to successfully manage the patient in accordance with accepted standards of good medical practice. Concurrent care may be reimbursed to providers of different specialties when the services are for unrelated diagnoses involving different organ systems.
Concurrent care will be denied when billed for providers of the same specialty for the same or related diagnoses. A diagnosis will be considered related when up to six digits match the primary ICD-10-CM diagnosis code. Denied concurrent care may be appealed when accompanied by documentation of medical necessity.
Each appeal submitted for concurrent care must contain the following information:
Claims appealed without clear documentation of medical necessity as described above will be denied.
Important:
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 must include, but is not limited to, documentation of:
9.2.56.6.3
Consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting must be billed using procedure codes 99251, 99252, 99253, 99254, and 99255.
One initial inpatient consultation (procedure code 99251, 99252, 99253, 99254, or 99255) is allowed for each hospitalization within a 30-day period. Subsequent consultations billed as initial consultations during this time period will be denied.
Refer to:
Subsection 9.2.56.1.3, “Consultation Services,” in this handbook for additional criteria information.
9.2.56.6.4
Critical care includes the care of critically ill clients that require the constant attention of the physician. The physician must either be at bedside or immediately available to the client. The physician’s full attention must be devoted to the client so that the physician cannot render E/M to any other client during the same period of time. Critical care is usually given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, neonatal intensive care unit, or the emergency department care facility. The following procedure codes are used to bill critical care services:
 
A per day charge for the first 30 to 74 minutes of critical care (time spent by the physician does not have to be continuous on that day).
A per day charge for each additional 30 minutes beyond the first 74 minutes of critical care for up to 6 units or 3 hours per day.*
A per day charge for initial inpatient pediatric critical care of the critically ill client who is 29 days through 24 months of age.
A per day charge for subsequent inpatient pediatric critical care of the critically ill client who is 29 days through 24 months of age.
A per day charge for initial inpatient pediatric critical care of the critically ill client who is 2 years through 5 years of age.
A per day charge for subsequent inpatient pediatric critical care of the critically ill client who is 2 years through 5 years of age.
* If the number of units is not stated on the claim, a quantity of one is allowed.
Services for a client who is not critically ill and unstable but who was treated in a critical care unit must be reported using subsequent hospital visit codes or hospital consultation codes.
If the same provider who performed a major surgery must also perform critical care on the same day for the same client, the provider must bill the critical care with documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure.
Critical care (procedure codes 99291, 99292, 99471, 99472, 99475, and 99476) may be reimbursed only to the provider rendering the critical care service at the time of crisis. Critical care involves high-complexity decision-making to access, manipulate, and support vital system functions. While providers from various specialties may be consulted to render an opinion and assist in the management of a particular portion of the care, only the provider managing the care of the critically ill patient during a life threatening crisis may bill the critical care procedure codes.
Critical care procedure codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured client, even if the time spent by the physician on that date is not continuous.
Actual time spent with the individual client must be recorded in the client’s record and reflect the time billed on the claim. The time that can be reported as critical care is the time spent engaged in work directly related to the individual client’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.
Time spent under the following circumstances may not be reported as critical care:
Critical care of less than 30 minutes total duration per day must be reported with the appropriate E/M procedure code.
If critical care that meets the initial 30-minute time requirement is provided to the same client by different physicians, the initial provider’s claim may be reimbursed. The second provider’s claim will be denied but may be appealed. The time spent by each physician cannot overlap; two physicians cannot bill critical care for care delivered at the same time. Supporting medical record documentation that includes the time in which the critical care was rendered must be provided by the second physician. In addition, a statement must be submitted indicating the physician was the only provider managing the care of the critically ill patient during the life threatening crisis.
If the provider’s time exceeds the 74-minute threshold for procedure code 99291, procedure code 99292 may be billed for each additional 30 minutes. Procedure code 99292 must be billed by the same performing provider or by a member of the same performing provider’s group practice and is limited to 6 units per day for any provider.
Inpatient critical care services provided to infants 29 days through 24 months of age are reported with pediatric critical care procedure codes 99471 and 99472. The pediatric critical care procedure codes are reported as long as the infant or young child qualifies for critical care services during the hospital stay through 24 months of age.
Pediatric critical care (procedure codes 99471, 99472, 99475, and 99476) is a per-day charge. Only one physician can bill pediatric critical care per day. If an inpatient or outpatient E/M service is billed by the same provider with the same date of service as pediatric critical care, the E/M service is denied.
Critical care provided to a neonatal, pediatric, or adult client in an outpatient setting (e.g., emergency room), which does not result in admission must be billed using procedure codes 99291 and 99292. Critical care provided to a neonatal or pediatric client in both the outpatient and inpatient settings on the same day must be billed using the appropriate neonatal or pediatric critical care procedure code.
If critical care (procedure code 99291 or 99292) is provided to a patient at a distinctly separate time from another outpatient E/M service by the same provider, both services may be reimbursed with supporting medical record documentation.
Prolonged physician services (procedure codes 99354, 99355, 99356, and 99357) will be denied when billed by the same provider with the same date of service as critical care (procedure code 99291, 99292, 99471, 99472, 99475, or 99476).
Claims may be subject to retrospective review to ensure documentation supports the medical necessity of the service when billing the claim.
Critical care procedure codes 99291 and 99292 will be denied when submitted with the same date of service by the same provider as neonatal intensive care procedure code 99468, 99469, 99478, 99479, or 99480.
9.2.56.6.5
Hospital discharge must be submitted using procedure code 99238 or 99239.
Discharge management billed by the same provider with the same date of service as the admission will be denied.
Discharge management billed by the same provider with the same date of service as an emergency room visit will be denied but may be reimbursed upon appeal if provided at a separate time.
Subsequent hospital visits billed by the same provider with the same date of service as discharge management will be denied.
Initial hospital visit procedure codes 99221, 99222, and 99223 billed with the same date of service as hospital discharge day management procedure code 99238 will be denied as part of another procedure billed on the same day. Initial hospital visit procedure code 99221 billed with the same date of service as hospital discharge day management procedure code 99239 will be denied as part of another procedure billed on the same day.
9.2.56.6.6
Providers must use the following when billing initial nursing facility assessments, subsequent nursing facility care, and annual nursing facility assessments in a nursing facility:
 
* Initial nursing facility assessments include all services related to an admission to the nursing facility.
Comprehensive initial nursing facility assessments performed by the same provider for the same diagnosis are limited to one every six months. The second initial nursing facility assessment within the six-month period will be denied.
Prolonged services in the nursing facility involving direct (face-to-face) patient contact that is beyond the usual service may be reimbursed on the same day as a nursing facility visit (procedure code 99304, 99305, 99306, 99307, 99308, 99309, or 99310).
Procedure code 99356 must be used to report the first hour of prolonged service and is limited to one per day.
Procedure code 99357 must be used to report each additional 30 minutes and is limited to a quantity of three units or one and one-half hours per day.
Prolonged physician services will not be reimbursed in addition to an emergency room visit billed on the same day.
All E/M services, regardless of setting, are considered part of the initial nursing facility care when performed by the same provider on the same day as the admission.
Subsequent nursing facility care E/M procedure codes 99307, 99308, 99309, and 99310 are limited to one per day regardless of diagnosis.
9.2.56.6.7
When a patient is admitted to the hospital as an inpatient and is discharged in less than 48 hours, the hospital may request that the physician change the admission order from inpatient status to outpatient observation status. This is an acceptable billing practice under Texas Medicaid when the physician makes the changes to the admitting order from inpatient status to outpatient observation status before the hospital submits the claim for reimbursement.
Refer to:
Subsection 9.2.56.1.5, “Observation Services,” in this handbook for more information about hospital observation.

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