ED Coding and Reimbursement Alert

Pay attention: The rules for reporting subsequent hospital care codes differ from ED E/M services.

When the ED physician is asked to see an admitted patient outside of the ED, the correct E/M code will likely be from the inpatient hospital care code section of CPT®. Take this advice on navigating the inpatient visits alternatives to pick the right one for your scenario. 

Trend spotlight: The increase in hospitalist coverage in many hospitals has significantly reduced the requirement for emergency physicians to provide care for admitted patients, so this scenario maybe unfamiliar to some coders.  But for coders working for ED groups that act as a safety net for inpatients, choosing the proper level of E/M service can be a confusing undertaking for two reasons.

1: A coder must consider the payer involved because Medicare policy differs from CPT® on use of consultations as opposed to initial or subsequent hospital care codes.

2: ED coders often under-report these services, resulting in a lower payout and hurting the facility’s overall finances. 

These challenges could occur if a coder doesn’t realize that they do not need to satisfy all of the E/M components to report the subsequent care codes, says Todd Thomas, CPC, CCS-P, and President of  ERcoder, Inc. in Edmond OK.

There are some tricky aspects of subsequent hospital care coding. But if you pay attention to the special rules and observe the documentation guidelines, you can ethically maximize your revenue for these services, says Thomas.

Consultation, Initial Hospital Care of Subsequent Hospital Care? Check The Payer Policy First

CPT® instructs use of an inpatient consultation code (99251-99255) for initial inpatient encounters other than by the admitting physician, especially if you are providing advice for the admitting physician. Be sure to report any procedures you may have to perform if documentation supports the service. 

Medicare factor: However, Medicare does not recognize consultations so it instructs all providers in the inpatient setting who perform an initial evaluation to a patient to report the initial hospital care codes (99221 – 99223). 

Only one doctor can be the principal admitting physician of record. The admitting physician should append modifier -AI (Principal Physician of Record) in addition to the appropriate E/M code. Medicare goes on to say that any follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits, Thomas explains.

Only Two Out Of Three E/M Components Are Required For Subsequent Care Codes

Your ED physician may provide subsequent hospital care to patients for several reasons, including contractual obligations, after-hours resource limitations, or general clinical responsiveness. 

Patients that may require subsequent hospital care from an ED physician include a floor patient who is having shortness of breath or chest pain. Frequently these “floor responses” will not meet the full requirements for critical care or for reporting a consult code. When you are a choosing service level for these encounters, you’ll decide between:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem focused interval history; an problem focused examination; medical decision making that is straightforward or of low complexity)
• 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity…) and 
• 99233 (… a detailed interval history; a detailed examination; and medical decision making of high complexity…).

But be careful when selecting a code from this family, because 99231-33 claims have different reporting rules than the standard ED E/M services. On many E/M services, such as 99281-99285, you must meet all three key components in their E/M description (history, the physical exam, and the medical decision-making). 

On a 99231-33 claim, however, the physician only has to meet two of the three key E/M components as opposed to three of three for an ED E/M code, confirms Thomas.

Example: Let’s say the ED physician provides subsequent hospital care to a patient. The notes indicate that he performed an expanded problem focused interval history with a problem focused examination. MDM was of moderate complexity.

You only need to have two out of three elements, so if the notes indicate a level 1 exam, but indicate interval history and MDM are level 2, then that’s all you need, Thomas explains.

What you’ll code: On the claim, report 99232 for the service.

Use H & P Documentation to Unlock Subsequent Care Claims

The interval history is the first step toward determining medical necessity, which is vital to proving service level on subsequent care claims.

Even though the code set 99231-99233 uses 2 out of 3 for history, exam, and MDM, interval history sets up the medical necessity for performing the type of exam and resulting MDM, Thomas explains. 

For example: Let’s say physician note’s indicate “patient’s emphysema unchanged from yesterday, stable.” That would not necessitate a detailed or comprehensive exam or a high MDM, suggesting a 99231 or 99232 level of service, he says. 

But, if interval history indicated “patient with chronic emphysema has worsened since yesterday, breathing labored, in acute distress, pain level +8,” then the physician would perform a more detailed exam and more complex MDM (e.g. because the physician prescribed medication, ordered more lab tests, etc.).  An encounter with this interval history — if properly documented — is likely to be a 99233 service says Thomas. 

MDM Will Often be the Deciding Factor for Subsequent Care Code Choice

The volume of documentation should typically not be the sole determinant of your level. The NOPP, while not a key element should be considered, says Thomas.  

Consider these guidelines:

Patient is stable, recovering or improving. This is likely a 99231 service.

Patient is responding inadequately to therapy or has developed a minor complication. You’ll use 99232 to report these types of scenarios.

Patient is unstable or has developed a significant complication or a significant new problem. These issues typically warrant 99233 services.

Caveat: These are not hard and fast rules, but are merely guidelines to steer you toward the proper subsequent hospital care code, says Thomas. No matter what service level you choose, be sure your documentation proves medical necessity and explains clearly what the physician did during the subsequent hospital care encounter, he warns.