EM Coding Alert

Don’t forget to use the right modifier where appropriate.

Knowing how to report inpatient evaluation and management (E/M) services is key for earning reimbursement for your clinicians’ work treating hospital patients after trauma or surgery.

E/M services have been on every coder’s mind with the 2021 updates to outpatient coding rules, but don’t forget that you still need to have a firm grasp on the 1995 or 1997 guidelines for history, exam, and medical decision making (MDM) components for many other E/M services.

Question 1: How Should I Code for an Admission?

Answer 1: Although coders commonly pore over the CPT® code book looking for an admission code, you should save the time before you go on the hunt. That’s because there aren’t any codes that relate specifically to hospital admissions. Instead, you’ll report one of the following codes for initial inpatient services for the admitting physician:

• 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity…)
• 99222 (… A comprehensive history, a comprehensive examination, and medical decision making of moderate complexity…)
• 99223 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity…)

The tricky part is knowing which provider is considered the “admitting physician.” That’s because only one physician is actually the one who admits the patient to the hospital. Anyone else billing initial hospital care is seeing the patient as a replacement for the consultation codes, as CMS has instructed consulting physicians to code initial hospital care even when they are not the admitting physician.

One easy way to break it down is to remember that for Medicare, the admitting service is identified with modifier AI (Principal physician of record). All other providers should bill the inpatient E/M codes that describe their participation in the patient’s care (i.e., subsequent hospital visit, or inpatient consultation [99251-99255]). In the case of Medicare, consultants will not be able to report 99251-99255 — instead, they are required to use initial hospital care codes 99221-99223 because Medicare no longer accepts consultation codes.

Regardless of the service type, only one claim can be reported per patient per specialty per group per day. In other words, physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. For example, if one physician sees the patient in the morning and another, who is covering for a colleague, sees the same patient in the evening, the notes for both services are combined and only one hospital visit is coded. However, if two physicians see the patient and they are in different specialties and are seeing the patient for different reasons, then both may bill a hospital visit based on that physician’s note and the medical necessity of the service.

Question 2: When Should I Use 99234-99236 for Initial Inpatient Care?

Answer 2: In some cases, your physician may see a patient who is admitted and discharged to observation or inpatient care on the same date. In these instances, you may look toward this code range:

• 99234 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity…)
• 99235 (… a comprehensive history; a comprehensive examination; and medical decision making that is of moderate complexity…)
• 99236 (… a comprehensive history; a comprehensive examination; and medical decision making that is of high complexity…)

The basic difference between the 99221-99223 range and these codes is that 99234-99236 represent the services of an initial hospital observation or inpatient hospital care service and a discharge service performed on the same calendar date. This means your documentation must reflect the exact times for admission and discharge.

To report 99234-99236 to Medicare, you must have a statement that shows the stay for care was greater than eight hours but less than 24 hours, according to Medicare Claims Processing Manual, Chapter 12, Section 30.6.8.

If inpatient admission lasts more than 24 hours, then you may consider using 99221-99223 for the initial day of hospital care.

There are instances where a patient can be in observation for up to 48 hours, in which case you’ll report code range 99218-99220 (Initial observation care…) alongside 99217 (Observation care discharge day management…) on the discharge date. It’s important to note that a patient can be in an inpatient bed, but still be considered in observation as an outpatient in some instances.

Question 3: How Should I Document Hospital Care?

Answer 3: First, the initial inpatient codes require you to document that the three key components of history, examination, and MDM appropriate to their levels have been met. The level of the encounter will be determined by the lowest documented level of the history, exam, and MDM since all three must be met for these codes. Weak documentation in one will pull the encounter down. Both the level 2 and 3 initial hospital visits require a comprehensive history and exam. The only difference is the MDM, with the level 2 requiring moderate and the level 3 requiring high. So, if the documentation of the history or exam does not reach a comprehensive level, the initial hospital service is held down to a level 1 or may not even meet the requirements for the first level.

Additionally, because 99234-99236 can represent observation or hospital services, the documentation should support the relevant service.

Question 4: Can You Code Inpatient Visits Based on Time?

Answer 4: Yes, you are able to code your inpatient visits based on time if counseling and coordinating care represents over 50 percent of the encounter time, but this can lead to some problems when determining which codes you should be reporting. Time is often underdocumented for inpatient E/M services. Providers don’t always remember to document time that is spent on the unit/floor that is outside the face-to-face time with the patient and family. Inpatient E/M time-based claims also require that more than 50 percent of the total visit time is spent counseling or coordinating care.

Another important thing to remember is the typical time for each code is different, as the following chart shows:

Question 5: How Should I Report Hospital Discharges?