Medicare Compliance & Reimbursement

Question: A Medicare inpatient was aggressive and needed restraints several times during his stay. In addition, he was put in seclusion after assaulting the staff several times during the night. This required the doctor to get to the hospital within an hour to authorize the seclusion, sedate the patient, calm staff, etc.

The doctor saw the patient during regular rounds on Jan. 1, was pulled into the hospital at 3 a.m. Jan. 2 because of the seclusion, and saw the patient for follow-up to seclusion during the daylight hours of Jan. 2. This is three visits within a 24-hour period. Do I code the second 99232 (visit during the daylight) with a modifier 59? Or must both visits on Jan. 2 be coded with a 59?

Answer: The codes for initial and subsequent inpatient visits are structured on a per-day basis, which means you should only report the applicable code once on a date of service.

In your case, you have two dates of service — Jan. 1 and Jan. 2. There appears to be a subsequent inpatient visit on Jan. 1. Code this as usual based on the history, exam, and medical decision making with the appropriate choice from 99231-99239 (Subsequent hospital care, per day, for the evaluation and management of a patient …). It is possible that the encounter could be an elongated visit that you could code based on time. For example, 99223 has a typical time of 70 minutes and 99233 has a typical time of 35 minutes.

On the second date (Jan. 2), all the activities in some sense would be added together. You shouldn’t have any difficulty in going to the highest level code based on a typical time of 35 minutes or more.

In terms of modifiers, appending 59 (Distinct procedural service) won’t be to your benefit. If a modifier were to apply, it might be 22 (Increased procedural services) because of specifics involved in dealing with the patient. Remember, however, that reporting modifier 22 won’t necessarily increase your reimbursement for care.