EM Coding Alert

Learn from these five case scenarios on core inpatient coding.

When you perform E/M visits for hospital patients, you’ve got to be on top of the appropriate hospital codes.

“There is an extreme need for physicians and their coding staffs to constantly work on understanding the E/M coding process, particularly the support documentation,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. Read on for real-world scenarios and solutions that will help you collect for your hospital services.

How Do You Capture the ‘Admit’ Code?

Example 1: A physician admits a patient to the hospital and asks the coder to report the admit code for the service. Where does one find it the manual?

Answer: CPT^® does not include a code for hospital admission itself, even though physicians often document that they performed an “admit.” The admitting physician should report codes 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) for his care if he documents the elements contained within the codes (appropriate history, exam, and medical decision-making). He is not billing for the admission itself—he’s billing for the care that he provides, based on the documentation.

CPT^® states that the initial hospital care codes “are used to report the first hospital inpatient encounter with the patient by the admitting physician.” Physicians get paid for the care they provide, not for administrative work. Processing the admission, including dictating the required H&P, counts as administrative work, not medical care.

“Note also that the date of admission in the hospital record may be different from the initial hospital care that a physician provides,” cautions Abbey. “A patient may present through the ER late in the evening, but the attending physician may not see the patient until the next morning. Obviously, the nuance between admission and initial care can create compliance issues.”

Do You Know How to Report Two E/M Codes?

Example 2: A patient is seen in the office for potential bronchitis, but on evaluation the provider diagnoses pneumonia. Based on her coexisting conditions (that is, having more than two ailments at the same time), he admits her to the hospital that same afternoon. In this case, should one report the outpatient E/M code, the inpatient E/M code, or both?

Answer: If you see a patient in your office and subsequently perform initial inpatient care for the same patient on the same date, you should report either the inpatient code or the office service; but, not both. Some coders will recommend submitting the inpatient E/M code. According to CPT^®, “when the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, office, nursing facility), all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.” CPT^® advises that you include the outpatient E/M notes when considering the level of inpatient service to report. However, if the physician performs most of the service in the office and then briefly sees the patient during that admission, then the office service would be the most appropriate code.

Remember: Suppose you perform a history of present illness and review of systems, ask about past, family and social history, and perform a detailed exam in the office setting. The decision-making results in wanting to send the patient to the hospital. When the physician sees the patient in the hospital, he’s probably not going to do all of those history elements again, so those become part of the documentation in the initial hospital care code that the doctor will report.

“Note that the location of the records may become an issue,” opines Abbey. “If the patient is seen at the physician’s office and is then taken to and admitted to the hospital as in inpatient, then some of the records may be in the physician’s office. Physicians will need to work with the given hospital to develop policies and procedures relative to either including such documentation in the hospital record or at least providing a note pointing to the location of the documentation. This same issue is present for direct referral from a physician’s office to observation at the hospital.”

Do You Need a Modifier for Same Day E/M and Surgery?

Example 3: The surgeon performs a hospital E/M service and then performs surgery on the same patient within the next few hours. Should modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) be appended to the E/M code?

Answer: If surgery immediately follows a hospital E/M service, you should append modifier 57 (Decision for surgery) to the inpatient E/M code to differentiate it from the usual preoperative exam included in the global package. If, however, the surgery is a minor procedure, perhaps one performed at the bedside, then the 25 modifier is the appropriate choice.

Plus: Suppose a patient presents to the hospital with abdominal pain after falling off a railing. During the history and physical, the patient begins to have abdominal pain, dizziness, and nausea. Concerned about the possibility of internal injury, the physician admits the patient and, upon diagnostic testing, identifies a liver laceration requiring surgical repair.

If surgery is performed the day of or the day after this type of admission to the hospital, you should append modifier 57 to the appropriate E/M code. Then, separately report the liver repair (47350, Management of liver hemorrhage ...) as well.

“Note that the 57 modifier applies to what Medicare classifies as major surgeries [i.e., 90-day post-operative period] as identified in the Medicare Physician Fee Schedule [MPFS] as delineated in RBRVS [Resource-Based Relative Value Scale],” tells Abbey.

When Multiple Providers Treat a Patient, Who Reports the Discharge?

Example 4: Suppose a patient has a complex health history, and is therefore under treatment from four different practices simultaneously. When one of the practices bills the discharge code, it gets denied. You learn that one of the other practices billed for the service first. Should that practice’s provider split the payment with the other physicians?

Answer: Several physicians might be managing the care of a patient, and all might try to bill for the discharge—but only the attending physician should collect for it, CMS indicates.

MLN Matters article MM5794 notes, “Only the attending physician of record (or physician acting on behalf of the attending physician) shall report the hospital discharge day management service (CPT^® code 99238 or 99239).” Any other physicians should instead report a subsequent hospital care code (99231-99233) for a final visit with the patient.

Keep in mind that sometimes a patient may not be eligible for a discharge code. This can happen in various circumstances, such as if the patient never left the emergency room and thus was never admitted as an inpatient. In this case the physician would report an ED service code (99281-99285).

“See also the AI modifier that identifies the principal physician of record,” adds Abbey.

What Constitutes Intensive Care?

Example 5: The doctor sees a patient in the intensive care unit (ICU). He circles critical care code 99291. Do all of his services become critical care services just because the place of service is ICU?

Answer: No, you cannot bill the critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes [List separately in addition to code for primary service]) simply because the place of service is the ICU.

Here’s why: Critical care is not location based — the term describes a type of care. The physician must meet three criteria before billing for critical care:

• The patient must have a critical illness or injury (usually defined as a critical organ system failure or a shock-like syndrome with a high probability of imminent or life threatening deterioration in the patient's condition)
• The physician must document at least 30 minutes of time spent directly with the patient or in the hospital unit, limited only to that patient.
• The physician must document highly complex decision making to assess, manipulate, and support vital system function(s) to treat the critical illness or to prevent further deterioration of the patient's condition.

Better option: If your physician evaluates a patient in the ICU but does not perform critical care services, you’ll report an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...) or an appropriate subsequent hospital care code (99231-99233).

“Note that the time the physician spends with a given patient may not be continuous, that is, the physician may spend 20 minutes, leave, and the come back and provide services for say another 15 minutes,” says Abbey. “This time can be accumulated, but documentation of the time and type of services becomes critical. See also the need to distinguish between services such as CPR (cardiopulmonary resuscitation) and critical care.”

Final takeaway: “E/M coding for physicians and practitioner for services provided in the hospital setting can be confusing and complex,” admits Abbey. “Physicians, as well as coding staff, need to be constantly vigilant to make certain that the documentation provided supports the E/M coding. Coding staff can work with physicians to improve documentation when problematic situations arise.”