On Jan. 30, Colorado Medical Society (CMS), Colorado Hospital Association (CHA), and the Department of Health Care Policy and Financing (HCPF) resolved outstanding concerns related to Medicaid audits regarding “Excessively Billed Evaluation and Management Initial Hospital Care Codes" (i.e., inpatient specialty audit).  

Since November 2022, there has been a coding disagreement regarding Health First Colorado billing audits for certain codes used when a physician sees a patient in the hospital for the first time and provides care that includes higher levels of medical decision-making. Specifically, the disagreement was about whether admitting providers and other specialty physicians can bill for the initial visit the first time they see the patient for any given hospital stay. HCPF will recognize that providers who are evaluating a patient for the first time can bill the initial hospital care code (codes 99221 to 99223) and has agreed to update the RAC audit to reflect these guidelines. Additional background on the audit can be found here.  

HCPF will reprogram the audit to exclude these codes moving forward. Also, it will resolve all existing cases flagged as part of this coding sequence that are in informal reconsideration and appeal. HCPF plans to release formal guidance at the end of February 2024 for how to resolve these claims. The other aspects of the audit will continue. For example, if two providers of the same specialty see the same patient for the same condition and improperly bill the same initial hospital care code, that will continue to be flagged as a violation of Medicaid and AMA coding policies.  

Categories: Resources, Practice Management, Coding and Billing, Initiatives, Advocacy