Neurology & Pain Management Coding Alert

Use 1 set of codes for initial hospital care.

With all the attention surrounding the revised office/outpatient evaluation and management codes in 2021, it can be easy to let your other E/M coding skills slip if you forget to focus on them.

The lowdown: While office/outpatient E/M codes have new descriptors, the other E/M codes do not. This includes hospital care codes, which you’ll continue to utilize in the same way you did in 2020. Keeping these E/M rules straight while mastering the new office/outpatient rules could be tricky, so be on alert.

Don’t fall out of practice on your other E/Ms; check out this rundown of the ins and outs of hospital inpatient coding.

Choose From Code Trio for Initial Day

When reporting your provider’s initial day of hospital care, you’ll choose from one of the following codes depending on encounter specifics:

• 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. …)

Important: Remember you need to satisfy all three elements for these codes: history, examination, and medical decision making (MDM) — unlike office/outpatient E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.), which had their descriptors altered radically for 2021.

As for whether you count all E/M services that day toward the overall code level, the answer is: it depends.

“All E/M services by the same specialty/same provider should be combined during that 24-hour period. If the hospitalist group, for example, was admitting the patient and then needed to see the patient later in the day, the information should be added together in support of one visit code with the AI modifier [Principal physician of record] indicating them as the admitting service,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “If a specialist sees the patient, that service could also be reported with a 99221-99223 code selection. The AI modifier would not be appropriate as the specialist wouldn’t be the admitting [physician].”

You should also be sure to include the correct documentation to solidify the claim, Hauptman says. The documentation would be that of all providers under the same specialty on the same calendar day: MDs, DOs, PAs, NPs, etc. “This would be notes that these providers actually write. It would not include hospital staff documentation, as that information would be considered when charging and coding the hospital services themselves,” explains Hauptman.

Rely on Different Set for Subsequent Care

When coding for subsequent hospital inpatient services, you’ll choose from one of the following codes, depending on encounter specifics:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A 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. …)
• 99233 (… A detailed interval history; A detailed examination; Medical decision making of high complexity. …)

Documentation is also key to choosing the correct subsequent hospital care code, Hauptman relays. “Here too, you are looking for the documentation written by the service as a whole. If only one provider sees the patient, it would be that note used to determine the appropriate level of service,”

she says. “If additional providers of the same service/same specialty see the patient; that information would be included in that code as well.”