# Inpatient level questions - My issue



## LLovett (Jan 9, 2009)

Admit codes (99221-99223) 

99221 requires a detailed or comprehensive history, detailed or comprehensive exam and medical decision making that is straight forward or low complexity.

99222 and 99223 require comprehensive hx, exam, and moderate (2) high (3) medical decision making.

My issue, what if the doctor is only documents an EPF exam but meets the detailed history and high complexity MDM. These codes are 3 of 3, so I am thinking we can't bill anything.

Obviously this is an educational issue but the charges I am working on are approaching a year old and the physician is no longer with us so I am just trying to clean up a mess.

The other problem I am having is when a patient is being followed by multiple providers, sometimes up to 6 different providers in an inpatient stay. What do you do when the primary care provider comes in and has no cheif complaint, minimal documentation and the only diagnosis they list are truly being mananged by the other providers (specialists) who are also seeing this patient each day.

Example of a progress note (these are of course handwritten)
"Feels well, l CTA, AB soft, IV site ok, pt INR NIT
A&P SP CABG, Hx of grafted vein, Hx of DVT, HTN"

This patient is being followed by both the cardiothoracic surgeon and her cardiologist among others and just had the CABG procedure 3 days prior to this. This note was by the IM doctor.

Advice and opinions are greatly appreciated.


Thanks

Laura, CPC


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## FTessaBartels (Jan 9, 2009)

*99499 and 99231*

Problem # 1
When you dont' have sufficient documentation to meet the standard for a 99221, use *EITHER* the unlisted E/M procedure code: 99499 *-or-* 99221-52 (reduced service modifier).  This came from a seminar I attended, and was carrier specific. Some carriers wanted the 99499, others wanted the -52 modifier on the 99221.  Also, be sure that you are auditing using BOTH 1995 and 1997 guidelines. Sometimes a note will meet the detailed exam level on the 1995 when it doesn't on the 1997. 

Problem # 2
Everyone after the admitting physician codes subsequent hospital visits, unless there is a legitimate consult requested and documented. (That's *not* the case for your example.)

Subsequent hospital visits require two of the three key elements: history, exam, MDM.  The Chief complaint is part of the history. Since it's missing, I would count the exam and MDM to determine level of service. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## LLovett (Jan 9, 2009)

Thanks Tessa.

Was the seminar done by WPS? Which one did they prefer? 

I have a real problem with the cheif complaint issue though. When you read in the guidelines it states a cheif complaint is indicated at all levels and it is not included in the elements of history that you use to determine the history level, which is what can be dropped for leveling purposes.


Thanks

Laura, CPC


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## FTessaBartels (Jan 10, 2009)

*Wps*

The coding symposium was put on by the Medical Society of Wisconsin. One of the panelists was from our Medicare carrier - WPS. I just went over my notes ... and unfortunately I didn't write down who wanted what (I'm in a Pediatric specialty so we virtually never deal with Medicare) ... but I seem to recall that WPS wanted the unlisted code.

At the same seminar one of the examples was for a subsequent hospital visit and I had the exact question you have ... where's the chief complaint?  I was told that it is a part of the history and that the note could be coded based on exam and MDM.  In fact in 2009 CPT Professional Edition, page 7, the E/M guidelines even show that "chief complaint" is always listed as part of the history component. 

I still educate (and nag) my docs to list a CC on all notes ... but apparently I can code a note for a subsequent hospital visit without it (assuming I have enough exam and MDM to meet at least the 99231).

F Tessa Bartels, CPC, CEMC


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## Belinda Frisch (Jan 10, 2009)

*A link*

http://www.medicalspecialtycoding.com/ezines/Specialty_Coding_Advisor_Feb2007.html

Go “unlisted” if less than 99221 is documented
Impress upon your doctors and coders that initial hospital visits not documented enough to qualify for code 99221 must default to unlisted E/M code 99499. Trying to code the service as a subsequent hospital visit violates correct coding principles.

Initial hospital care code 99221 will net you about $85 this year – but only when your physicians document at minimum a “detailed” history and exam, and medical decision-making (MDM) of “straightforward” complexity. What happens when the documentation falls short of those requirements? an attendee asked panelists at the American Medical Assoc. (AMA) CPT and RBRVS 2007 Annual Symposium Nov. 16-17 in Chicago. The replies:
“You could use the unlisted code,” says Peter Hollmann, MD, senior medical director at Blue Cross and Blue Shield of Rhode Island and a CPT Editorial Panel member. CPT guidelines say all three key components must be met for the initial hospital care codes, he points out, so you can't use 99221 even if documentation for two of the three components qualifies.

“You guys are stuck because the doctor didn't do it right,” adds Richard Whitten, MD, a practicing general internist and medical director for Medicare's Part B carrier for Washington, Alaska and Hawaii. From a CPT point of view the unlisted code is OK. Medicare says a follow-up hospital visit code (99231-99233) isn't appropriate, although some carriers may allow it, he also cautions.

The reason you should not default to a subsequent hospital visit code when documentation isn't adequate? The intent of the service is initial care, and correct coding dictates that you stay within the category of codes that accurately defines the service – in this case, “initial hospital care” (see Coding Pro 11/06). 

Also remember: 99221-99223 may only be assigned appropriately by the admitting physician or group, and they may be used only once per hospitalization. The first visit by any other physician who sees the patient while in the hospital must be coded as either an inpatient consultation (99251-99255) or subsequent hospital care (99231-99233) (see ICD-9/CPT Coding Pro 11/06).


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## sgoodknight (Mar 3, 2009)

For subsequent hospital care:

In seminars that I have attended a chief complaint is not necessary for CPT codes 99231-3.  What auditors are looking for is interval histories.


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