Outpatient Billing with an ABN (Occurrence Code 32)

The billing instructions in this subsection apply to payment condition 2.

If an ABN is given, the billing procedures in this subsection must be used, rather than traditional demand billing. Using an ABN is frequently required, and is also allowed on a voluntarily basis when a provider sees fit. It is used more often than traditional demand billing.



Claim level coding

When a provider determines the beneficiary’s services for certain benefits should be terminated, the provider must follow the ED instruction requirements located at section 150.3 below. If the beneficiary chooses to receive non-covered services after the date the provider believes covered services are terminated, the provider must also issue an ABN to the beneficiary.

In using the ABN, beneficiaries select only one option on the ABN notice prior to billing, after they have been told that the provider anticipates Medicare will not cover a service. Claims, other than HHPPS claims, billed in association with an ABN never use condition code 20 or 21, and will be returned to providers if received with those codes. Instead, the claims:

• Must use occurrence code 32 to signify all services on the claim are associated with one particular ABN given on a specific date, unless the use of modifiers makes clear that not every line on the claim is linked to the ABN;

• Must provide the date the ABN was signed by the beneficiary in association with the occurrence code;

• Must use occurrence code 32 and the accompanying date multiple times if more than one ABN is tied to a single claim for services that must be bundled/billed on the same claim;

• Must submit all ABN-related services as covered charges (note –GA modifier exception, below); and

• Must complete all the same basic required claim elements as comparable claims for covered services.



Providers should be aware CMS may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN.

If claims using occurrence code 32 remain covered, they will be paid, RTP’ed, rejected or denied in accordance with other instructions/edits applied in processing. Denials made through automated medical review of service submitted as covered are still permitted after medical review, and the Medicare contractor will determine if additional documentation requests or manual development of these services are warranted. For all denials of services associated with the ABN, the beneficiary will be liable.



Line level coding

The –GA modifier is used when provider must bill some services which are related and some which are not related to a ABN on the same claim. The –GA modifier is used when both covered and non-covered service appear on an ABN-related claim. Occurrence code 32 must still be used on claims using the –GA modifier, so that these services can be linked to specific ABN(s). In such cases, only the line items using the –GA modifier are considered related to the ABN and must be covered charges, other line items on the same claims may appear as covered or non-covered charges.


 Line-Item Modifiers Related to Reporting of Non-covered Charges When Covered and Non-covered Services Are on the Same Outpatient Claim

Noncovered Charges on Inpatient Bills

No Payment Inpatient Hospital and SNF Claims. Where stays begin with a non-covered level of care and end with a covered level (within the same month for SNF billing), only one claim is required for both the non-covered and covered period, which must be billed in keeping with other billing frequency guidance (i.e., SNFs are required to bill monthly). However, SNFs and inpatient hospitals are required to submit discharge bills in cases of no payment. These bills must correctly reflect provider and beneficiary liability (see Chapter 6, §40.6.4 of this manual)

For inpatient hospital PPS claims that cannot be split into covered and non-covered periods, hospital providers can submit occurrence span code 77 to represent provider-liable non-covered periods, and occurrence span code 76 for beneficiary-liable non-covered periods.

These procedures must be followed for Part A inpatient services (TOBs: 11x (hospital), 18x (swing bed), 21x (SNF), 41x (religious non-medical health care institutions—RNHCI)), but the list that follows is not required for inpatient Part B claims:

• All charges submitted as non-covered;

• Frequency code 0 (zero) must be used in the third position of the type of bill

(TOB) form locator of the original claim (i.e., not adjustment or cancellation)

NOTE: If providers do not submit no payment claims with this frequency code, the shared systems may already act to change the frequency code to 0 or return the claim to the provider.

• Total charges must equal the sum of non-covered charges;

• Basic required claim elements must be completed;

NOTE: Units are not required when reporting non-covered days on SNF claims or Inpatient Rehabilitation claims.

Claims that do not conform to these requirements will be returned to providers. For SNFs, occurrence code 22 should also be used on benefits exhaust claims when SNF care is reduced to a non-covered level and benefits had previously been exhausted

When an Inpatient Admission May Be Changed to Outpatient Status

 Background

Payment is made under the hospital Outpatient Prospective Payment System (OPPS) for Medicare Part B services furnished by hospitals subject to the OPPS, and under the applicable other payment methodologies for hospitals not subject to the OPPS. “Outpatient” means a person who has not been admitted as an inpatient but who is registered on the hospital or critical access hospital (CAH) records as an outpatient and receives services (rather than supplies alone) directly from the hospital or CAH.

Under the hospital Condition of Participation (CoP) at 42 C.F.R. §482.12(c), patients are admitted to the hospital or CAH as inpatients only on the recommendation of a physician or licensed practitioner permitted by the State to admit patients to a hospital. In addition, every Medicare patient must be under the care of a physician or other type of practitioner listed in the regulation (“the practitioner responsible for care of the patient”). In some instances, a practitioner may order a beneficiary to be admitted as an inpatient, but upon reviewing the case, the hospital’s utilization review (UR) committee determines that an inpatient level of care is not medically necessary.

Taking this into consideration, CMS obtained a condition code from the National Uniform Billing Committee (NUBC), effective April 1, 2004, that specifies:

Condition Code 44--Inpatient admission changed to outpatient – For use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria.

The utilization review requirements for hospitals and CAH are found in their respective CoPs at §482.30 or §485.641. The hospital must ensure that all the UR activities, including the review of medical necessity of hospital admissions and continued stays required by §482.30(d), are fulfilled as described in the regulation. Section 482.30(d) delineates requirements that hospitals must follow when making the determination as to whether an admission or discharge of a patient is or was medically necessary. Review of admissions may be performed before, at, or after hospital admission. More information about the hospital CoP may be found in Pub.100-07, State Operations Manual, Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Section 485.641 requires CAHs to have a similar program for the evaluation of all services they furnish, including the quality and appropriateness of diagnoses and treatments furnished by their staff physician and non-physician practitioners. If in addition to making a medical necessity determination (or evaluating the appropriateness of diagnosis and treatment in a CAH) a hospital or CAH wishes to change a patient’s status from inpatient to outpatient, the following requirements apply.

CMS set the policy for the use of Condition Code 44 to address those relatively infrequent occasions, such as a late-night weekend admission when no case manager is on duty to offer guidance, when internal review subsequently determines that an inpatient admission does not meet hospital criteria and that the patient would have been registered as an outpatient under ordinary circumstances. The State Operations Manual states that in no case may a non-physician make a final determination that a patient’s stay is not medically necessary or appropriate (see Appendix A - Survey Protocol,

Regulations and Interpretive Guidelines for Hospitals). However, CMS encourages and expects hospitals to employ case management staff to facilitate the application of hospital admission protocols and criteria, to facilitate communication between practitioners and the UR committee or Quality Improvement Organization (QIO), and to assist the UR committee in the decision-making process. Use of Condition Code 44 is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital’s existing policies and admission protocols. As education and staffing efforts continue to progress, the need for hospitals to correct inappropriate admissions and to report Condition Code 44 should become increasingly rare.

Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day

D. Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day 

Contractors pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.


If a surgeon is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission and care with a modifier “-24” and provides documentation that the service is unrelated to the surgery (e.g., return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge from the hospital for cholecystectomy).

Contractors do not pay for a nursing facility admission by a surgeon in the postoperative period of a procedure with a global surgical period if the patient’s admission to the nursing facility is to receive post operative care related to the surgery (e.g., admission to a nursing facility to receive physical therapy following a hip replacement). Payment for the nursing facility admission and subsequent nursing facility services are included in the global fee and cannot be paid separately.



E. Hospital Discharge Management and Death Pronouncement

Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, CPT code 99238 or 99239.

The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date

Patient seen on hospital and office clinic same day - Billing guide

SPLIT/SHARED E/M SERVICE

Office/Clinic Setting

In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s UPIN/PIN. When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient. If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.

Hospital Inpatient/Outpatient (On Campus or Off Campus)/Emergency Department Setting

When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim.



EXAMPLES OF SHARED VISITS

1. If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

2. In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s UPIN/PIN.

In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The MAC has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The MAC also determines the payment based on the applicable percentage of the physician fee schedule depending

on whether the claim is paid at the physician rate or the non-physician practitioner rate. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose.

Hospital Discharge Day Management Service CPT CODE 99238 , 99239

Hospital Discharge Day Management Services, CPT code 99238 or 99239 is a face-to-face evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay.

Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range 99231 – 99233) for a final visit.

Medicare pays for the paperwork of patient discharge day management through the pre- and post- service work of an E/M service.



Subsequent Hospital Visit and Discharge Management on Same Day

Pay only the hospital discharge management code on the day of discharge (unless it is also the day of admission, in which case, refer to §30.6.9.1 C for the policy on Observation or Inpatient Care Services (Including Admission and Discharge Services CPT Codes 99234 - 99236). Contractors do not pay both a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician. Instruct physicians that they may not bill for both a hospital visit and hospital discharge management for the same date of service.

Initial Hospital Care Service History and Physical That Is Less Than Comprehensive CPT 99499

When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code.

Physicians who provide an initial visit to a patient during inpatient hospital care that meets the minimum key component work and/or medical necessity requirements shall report an initial hospital care code (99221-99223). The principal physician of record shall append modifier “-AI” (Principal Physician of Record) to the claim for the initial hospital care code. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.

Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010,where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.


Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.

Patient seen in Emergency department after admitted in Hospital? and Medicare downcoded the CPT ?

Q. If a patient is seen in the emergency department, then admitted to the hospital, how should this be billed?
A. As stated in the CMS Internet-only Manual:
Contractors pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

CPT® code 99058 not recognized as a billable service by Medicare program

Q. We treated a patient in the office on an emergency basis. CPT® codes 99212-25 (Office or other outpatient visit, with modifier 25 to indicate a significant, separately identifiable E/M visit on the same date as another procedure), 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) and 51705 (Change of cystostomy tube; simple) were billed. Can we be reimbursed for the office ER code 99058?

A. Current Procedural Terminology® (CPT®) code 99058 is not a recognized service billable to the Medicare program. The services are billed according to the actual level of care provided to the patient. There is no additional reimbursement for disruption of other scheduled office services.


Q. We submitted a claim with HCPCS code 99233 (Subsequent hospital care) to Medicare and it was downcoded to 99232. Upon inquiring why this change was made, we were told levels were compared to levels of other doctors who were seeing the patient on the same day. Is this correct?

A. No, this is not correct.
In order for the Medical Review department to downcode an E/M service, the documentation is reviewed. In this case, the nurse reviewer must have been unable to identify all elements required for the level of care being billed. In all cases, you should review the records you submit to verify if the correct level of care was selected based on the 1995 or 1997 E/M guidelines. If you disagree with the findings, you may request an appeal, wherein a new reviewer will look at the documentation provided.

Hospital visit CPT code 99221, 99222, 99223 Requirements

Evaluation & management tips: Initial hospital care, new or established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History,
2. Examination, and
3. Medical decision-making.
When billing initial hospital care, all 3 key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.
CPT codes and requirements

99221 - 30 minutes (average)

• Detailed OR comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Detailed - Extended review of systems; Pertinent past, family and or social history
• Comprehensive - Complete review of systems; Complete past, family, and social history
• Detailed OR comprehensive examination. Documentation needed:
• Detailed - Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
• Comprehensive - General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
• Medical decision making that is straightforward OR of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Straightforward - Minimal number of diagnoses or management options; None or minimal amount and/or complexity of data to be reviewed; Minimal risk of significant complications, morbidity and/or mortality
• Low complexity - Limited number of diagnoses or management options; Limited amount and/or complexity of data to be reviewed; Low risk of significant complications, morbidity and/or mortality

99222 - 50 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
• Medical decision making that is moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99223 - 70 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality