RAC Region B CGI posted an automated review issue that was approved on Feb. 2, 2014 for providers regarding initial hospital procedure codes 99221-99223 and Subsequent procedure codes (99231-99233) which are considered “per diem” codes and cannot be used by the same specialty providers from the same group practice.

The issue references retired Local Coverage Article:  Initial Hospital Care Visits – Medical Policy Article (A48210):

A physician or qualified non-physician practitioners can admit patients to the hospital and may bill Medicare for an Initial Hospital Care visit.

The Initial Hospital Care visit codes (99221-99223) may be billed by the admitting provider (physicians or qualified non-physician practitioners (NP, PA, CNS or CNM), once per beneficiary per hospitalization. Providers may not bill for both an admission visit (using CPT codes 99221-99223) and a separate discharge visit on the same day.

The issue also references the Centers for Medicare & Medicaid Services (CMS) publication, 100-04 Medicare Claims Processing Manual, Chapter 12 – Physicians/Non-Physicians Practitioners Section 30.6.9 Payment for Inpatient Hospital Visits – General as further guidance.

RAC Issues for the Week of March 17 – March 21, 2014:

RAC Region B CGI


  • Excessive Units of Hospital Visits – NGS – Both Initial Hospital Care codes (CPT codes 99221 – 99223) and Subsequent Hospital Care codes (CPT Codes 99231 – 99233) are “per diem” services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice.

  • PF Observation Care Billed with Discharge Services on the Same Day – J8 (WPS) – An issue exists where discharge services have been reported incorrectly with Observation Services on the same date of service. This automated review will identify the incorrect reporting of discharge services when billed on the same day as an Observation Service for a beneficiary.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.

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