Hospital-Based Visits Billed with Other Services

The edits described below apply to claims processed under the new claims processing system. Nevertheless, HMSA suggests that practitioners adopt the guidelines when filing claims to HMSA for all private business claims.

The code edit changes described in the guidelines below will not override HMSA’s existing medical policies.

The following code edits apply to hospital-based visits billed with other services.

Modifiers

When billing hospital-based visits with other services, it is important to bill accurately. In some cases, a modifier code must be appended to the visit code to ensure that both services are paid when appropriate. The following modifiers may be used for this purpose: 24, 25, and 57. Practitioners are urged to familiarize themselves with the criteria listed in CPT and the following policies.

• Modifier Code 25
• Modifier Code 57
• Preoperative Visits
• Postoperative Visits

Modifier codes should only be used when the service meets the criteria described in CPT and the policies. HMSA will perform postpayment reviews of modifier usage as needed to verify modifiers were used as described. If postpayment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.

Specific edits

Inpatient: Admissions, subsequent hospital visits, discharges

If an inpatient hospital visit is done in conjunction with any of the service codes listed below, and the hospital visit service meets criteria for the use of modifier codes 24, 25, or 57, the appropriate modifier should be appended to the hospital visit code. Note: The presence of the modifier does not guarantee payment if the modifier is not applicable or other payment policies apply.

The following codes are frequently billed by providers without modifiers when paired with inpatient hospital visits. When these services are billed, if the appropriate modifier is not appended to the hospital visit code, the hospital visit may not be paid.

Admissions (99221 - 99223)

Subsequent Hospital Care (99231 - 99233)

Discharges (99238 - 99239)

Outpatient: ER, observation

If an outpatient hospital visit is done in conjunction with any of the service codes listed below, and the hospital visit service meets criteria for the use of modifier codes 24, 25, or 57, the appropriate modifier should be appended to the hospital visit code. Note: The presence of the modifier does not guarantee payment if the modifier is not applicable or other payment policies apply.

The following codes are frequently billed by providers without modifiers when paired with outpatient hospital visits. When these services are billed, if the appropriate modifier is not appended to the hospital visit code, the hospital visit may not be paid.

Emergency department services (99281 - 99285)

[1] When this procedure is billed, HMSA’s old claims processing system will allow payment only of the higher-valued procedure, either the visit or procedure. Under the new system, both may be paid if criteria are met for the use of an appropriate modifier.

Observation (99234 - 99236)

Other hospital visit types: Inpatient consultations, critical care, pediatric critical care, newborn care

If a hospital visit is done in conjunction with any of the service codes listed below, and the hospital visit service meets criteria for the use of modifier codes 24, 25, or 57, the appropriate modifier should be appended to the hospital visit code. Note: The presence of the modifier does not guarantee payment if the modifier is not applicable or other payment policies apply.

The following codes are frequently billed by providers without modifiers when paired with hospital visits. When these services are billed, if the appropriate modifier is not appended to the hospital visit code, the hospital visit may not be paid.

Inpatient consultations (99251 - 99255)

Critical care (99291 - 99292)

Pediatric critical care (99293 - 99294)

Newborn care (99431 - 99435)

Note: The lists above are not all inclusive, but represent codes from various sections of CPT that are most commonly billed with a hospital-based visit and to which these guidelines apply.

Revision History