Payment for Inpatient Hospital Visits - General

30.6.9 - Payment for Inpatient Hospital Visits - General (Rev. 11842; Issued; 02-09-23 Effective:01-01-23; Implementation: 05-09-23) Starting in CY 2023, hospital inpatient and observation care by practitioners will be billed using the same CPT codes, CPT codes 99221 through 99223, 99231 through 99233, and 99238 and 99239. (CPT 99234 through 99236 are already used for billing hospital inpatient or observation care (including admission or discharge.) Where they appear, references such as “hospital care,” “hospital E/M” or “hospital inpatient care services” in this section apply to Hospital Inpatient or Observation Care Services codes (CPT codes 99221-99223, 99231- 99239.) A. Hospital Visit and Critical Care on Same Day Hospital evaluation and management (E/M) visits may be billed the same day as critical care services in certain circumstances discussed in section 30.6.12. Documentation must support the claims as indicated in that section. During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 - 99233. Both Initial Hospital Care (CPT codes 99221 - 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. B. Two Hospital Visits Same Day The time counted toward the Hospital Inpatient or Observation Care codes is “per day.” “Per day,” also referred to as “date of encounter,” means the “calendar date.” When using MDM or time for code selection, a continuous service that spans the transition of 2 calendar dates is a single service and is reported on one date, which is the date the encounter begins. If the service is continuous, before and through midnight, all the time may be applied to the reported date of the service (that is, the calendar date the encounter began). A billing practitioner shall bill only one of the hospital inpatient or observation care codes for an initial visit, a subsequent visit, or inpatient or observation care (including admission and discharge), as appropriate, once per calendar date. The practitioner selects a code that reflects all of the practitioner’s services provided during the date of the service. The definitions of “initial visit” and “subsequent visit” for the purposes of billing observation care using the Hospital Inpatient or Observation Care Services codes can be found in section 30.6.9.E. A/B MACs (B) pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. Note that in some cases, practitioners may bill a prolonged code in addition to the Hospital Inpatient or Observation Care Services base code; time spent by the same practitioner on the same day for the same patient in multiple settings (or for a patient who transitions between outpatient and inpatient status) may be counted toward the Hospital Inpatient or Observation Care Services base code and, if applicable, a prolonged code. Refer to section 30.6.9.F.) C. Hospital Visits Same Day But by Different Physicians In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, A/B MACs (B) do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day. If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty. D. Visits to Patients in Swing Beds If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply. E. Definition of Initial and Subsequent Visit An initial service is one that occurs when the patient has not received any professional services from the physician or NPP or another physician or NPP of the same specialty who belongs to the same group practice during the stay. A subsequent service is one that occurs when the patient has received any professional services from the physician or NPP or another physician or NPP of the same specialty who belongs to the same group practice during the stay. F. Prolonged Hospital Inpatient or Observation Care Services Beginning January 1, 2023, prolonged services are reported for certain hospital inpatient or observation care visits using G0316. Prolonged services can be reported when time is used to select visit level, and the total practitioner time for the highest-level visit is exceeded by 15 or more minutes for services that are medically reasonable and necessary. See Prolonged Services section below for detailed reporting instructions.