Neurosurgery Coding Alert

Use 1 set of codes for initial hospital care.

There’s been a ton of attention paid to the revised office/ outpatient evaluation and management (E/M) codes in 2021; so much so that it might affect how sharp your coding skills are for other E/M services.

Know this: 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.

Check out this quick rundown of hospital inpatient coding, so you don’t fall out of practice coding your other E/Ms.

Initial Day Marked by This Code Trio

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 components 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: medical doctors (MDs), doctors of osteopathic medicine (DOs), physician assistants (PAs), nurse practitioners (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.

Consider the following clinical scenario:

The surgeon is called by the emergency department (ED) physician to see a 72-year-old man who tripped at home and fell down the stairs, resulting in very weak and numb hands and difficulty with walking. The ED physician found mild quadriparesis primarily affecting the distal arms and obtained a magnetic resonance imaging (MRI) of the cervical spine showing severe cervical stenosis at several levels; worst at C56, where there was increased cord signal suggesting an acute spinal cord injury. A cervical computed tomography (CT) did not show a fracture or malalignment. The surgeon sees the patient and admits him for the purpose of monitoring blood pressure and heart rhythm, maintaining a high normal blood pressure, and immobilizing him in an effort to avoid progressive spinal cord injury.

Despite not planning a surgical treatment initially in the absence of a traumatic fracture and/or dislocation, you complete a comprehensive history and examination and document high-complexity medical decision making (MDM) that included review of multiple imaging studies, instituting treatment to avoid hypotension, discussion about the role and timing of spinal cord decompression surgery, and discussion with the patient about the role and limitation of high dose intravenous steroids. You also review the early risks of deterioration of neurological function.

For this encounter, you’d report 99223 with S14.125A (Central cord syndrome at C5 level of cervical spinal cord, initial encounter) appended to represent the patient’s injury.

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.”

Consider this example, which is from day 2 of the inpatient admission patient scenario explained earlier in the article:

The surgeon sees the patient the next day, identifying no clinical change in the patient. They perform an expanded problem focused history, detailed examination, and straightforward MDM. No treatment changes are needed.

For this encounter, you’d report 99232 with S14.125D (Central cord syndrome at C5 level of cervical spinal cord, subsequent encounter) appended.

30-Minute Mark Crucial for Discharge Code Choice

When the provider discharges the patient, you’ll choose from one of the following codes, depending on encounter specifics:

• 99238 (Hospital discharge day management; 30 minutes or less)
• 99239 (… more than 30 minutes)

Important: Keep in mind that the discharge service is bundled into most procedure codes and would therefore generally not be reportable if a procedure was performed by the discharging physician during the hospitalization.

When you can rightfully report 99238 or 99239, the codes include the following services in their work units:

• The final evaluation of the patient;
• Summary of the hospital visits (including final diagnosis/es);
• The treatment plan; and
• The follow-up plan.

Documentation alert: “The documentation should include the final exam elements as well as the information around the discharge — i.e. education, meds, follow-up, course of care, etc. — along with the time spent in the activity of the discharge,” Hauptman reminds.