EM Coding Alert

Let our experts help you evaluate and manage service level determinations.

When a provider is called upon to provide care for one of your patients following a hospital admission, coders know they should immediately flip to the 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …) codes in their CPT^® manuals. But assigning the correct code for the level of service can be an intimidating task.

Why? Like most evaluation and management (E/M) services, coding subsequent care requires you to apply an elaborate formula based on the level of history taken, the detail of the exam, and the complexity of the medical decision making (MDM). And as if that wasn’t enough, the subsequent care codes also involve some subtle guideline differences as well.

But there’s no need to be confounded. Simply spend some time with these scenarios and let our experts’ analysis help you code subsequent care services with care.

Breaking Down the Codes

Like other E/M codes, 99231-99233 describe increasingly severe medical conditions and an increasing amount of work on the provider’s part to treat them. Each also describes an increasing amount of typical time spent at the bedside and on the patient’s hospital floor or unit.

On the patient side, the conditions range from the lowest level, where the patient is stable, recovering, or improving, to the highest, where the patient is unstable and getting worse because he or she has developed a significant complication or a significant new problem.

On the provider side, the codes reflect reviews of the condition’s history, an examination of the patient, and level of medical decision making (MDM) appropriate for treating the patient.

From the provider’s perspective, the codes follow similar guidelines to many of the other E/M codes. Two of the three key components — history, exam, and MDM — need to be present in the documentation to support the level of service if coding on that basis, and if MDM is one of those components, two of three MDM components (number of diagnoses/management options; amount or complexity of data to be reviewed; or risk of complications and/or morbidity or mortality) need to be present to determine the level of MDM complexity.

Both sides of this E/M equation can be summarized in the following table.

What are the Similarities and Differences Between 99231-99233 and Other E/M Codes?

The main difference is in the level of history taken. CPT^® describes it as an “interval” history, which is basically a history of the patient’s condition since the last time the patient was seen. This means, as the Centers for Medicare and Medicaid (CMS) puts it, “it is not necessary to record information about the PFSH [past family and social history]” (Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf).

Test Your Subsequent Care Knowledge with These Scenarios

Now that you’ve reviewed the codes, read the following scenarios and match them with the appropriate level of subsequent care. We’ve added our experts’ opinions to help.

Scenario 1: Patient was admitted for a myocardial infarction (MI) and is now experiencing premature ventricular contractions (PVCs) on a frequent basis. Provider conducts a brief interval history of the present illness and a problem-pertinent system review; performs a limited examination of the cardiovascular system; reviews the moderate amount of data contained in some diagnostic tests and records; and considers how to manage the patient’s multiple diagnoses (i.e., MI and PVCs).

Analysis: Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, argues that this scenario meets the criteria for coding 99232, as two of three key components of the code have been met: the provider has conducted an expanded problem-focused history; provided a problem-focused examination of the affected organ system; and arrived at a moderate level of MDM based on the review of the moderate amount of the patient’s data and the management of the patient’s multiple conditions.

Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, agrees, noting that “had either the history or MDM been lower, then the two out of three would not have been met. And even with the PVCs,” Johnson adds, “the patient is not defined as unstable.”

Scenario 2: A 42-year-old female, admitted for acute gastroenteritis and dehydration and requiring intravenous (IV) hydration, is now stable but refusing oral intake. Provider conducts a brief interval history of the present illness and a limited exam of the gastrointestinal system; reviews a minimal amount of data; and orders more IV fluids without additives.

Analysis: Both Moore and Johnson believe this scenario matches the lowest level of subsequent care — 99231. Again, as Johnson notes, all the criteria for the code have been met. “The scenario requires a problem-focused history and exam and straightforward decision making,” Johnson observes, adding that “the refusal of oral intake would be considered a minor problem.” And Moore notes that the IV order “reflects a low-risk management option in the table of risk pertinent to MDM.”

Scenario 3: Patient admitted for acute respiratory distress. Now in second day, patient has developed an acute fever, dyspnea, and hypoxemia. Provider notes the location, quality, severity, and timing of the current condition; performs a problem-pertinent system review, which includes reviewing a limited number of additional systems; reviews the patient’s family and personal history of smoking and chronic obstructive pulmonary disease (COPD); conducts an extended examination of the cardiovascular, respiratory, hematologic, and immunologic systems; and an extensive assessment of the patient’s medical chart, test results, and the risk of complications associated with the patient’s condition.

Analysis: Subsequent care for this patient would rise to the highest level, or 99233. Moore notes the provider has obtained a PFSH and has conducted a detailed examination of several organ systems related to the patient’s condition. And both Moore and Johnson view the presenting problem as having a high level of risk as defined in the E/M guidelines. As Johnson puts it, the condition meets “the definition of unstable as the patient has developed a complication or new problem that is significant.”