Ophthalmology and Optometry Coding Alert

Remember: Hospital E/M coding rules didn’t change last year.

All the changes to the office or other outpatient evaluation and management (E/M) codes last year have led to plenty of confusion about many of the other E/M codes. That includes inpatient codes 99221-99223/99231-99233 (Initial/Subsequent hospital care, per day, for the evaluation and management of a patient …) and observation codes 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date …).

CPT^® will eventually revise these codes in the way they have revised 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). In the meantime, to use the inpatient codes correctly, you’ll need to separate fact from fiction by busting the following myths.

Myth 1: You Can Choose Inpatient Care the Same Way as Outpatient Care

This is a myth and a very significant red flag. The inpatient care codes 99221-99223, 99231-99233, and 99234-99236 were not revised in 2021. While you still have the choice to determine the level of inpatient and office/outpatient E/M codes based on time, the documentation and calculation of time requirement for inpatient codes still follow 1995/1997 E/M documentation guidance. Also, the level of hospital care cannot be determined on medical decision making (MDM) alone.

You must continue to determine the level of inpatient care using the three key components of history, examination, and MDM. For 99221-99223 and 99234-99236, that means determining the level of care using all three elements; for 99231-99233, two out of the three elements are necessary. As always, the elements “must meet or exceed the stated requirements to qualify for a particular level of E/M service,” per CPT^® guidelines.

Use this example to refresh your inpatient coding memory: Your ophthalmologist admits a patient to the hospital. On the day of admission, the provider performs a detailed history, a detailed exam, and exercises moderate-complexity MDM based on multiple diagnoses and a moderate risk of complications associated with the patient’s problems.

Based on this, you can assign an inpatient hospital care level of 99221. While the moderate MDM exceeds the code requirements, the detailed history and exam only meet them and do not allow a higher-level code.

Myth 2: Counseling Does not Have to Be More Than 50 Percent to Code Based on Time

While time is a factor for calculating the level of office/ outpatient services, you no longer need to meet the 50-percent rule for outpatient E/M visits. However, the 50 percent rule still applies for inpatient care codes. You still follow the 1995/1997 E/M documentation rules for calculating time in the inpatient setting when using inpatient care level codes.

In fact, CPT^® guidelines for the inpatient codes have not changed, and you can still count “the time present on the patient’s hospital unit and at the bedside rendering services for that patient … [and] time to establish and/or review the patient’s chart, examine the patient, write notes, and communicate with other professionals and the patient’s family” the same way you always have.

A word to the wise: Time is often underreported 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.

In addition, remember that the typical times for each of the codes are all very different from one another, as the following chart shows:

Myth 3: You Can Use 99221-99223 or 99234-99236 Interchangeably for Initial Inpatient Care

This is a myth, because the basic difference between the codes is that 99234-99236 represent an initial hospital 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 bill 99234-99236, you must have a statement that shows the stay for observation care or inpatient hospital care was greater than eight hours but less than 24 hours. If the admission is greater than 24 hours, use 99221-99223 for the initial day of inpatient hospital care.

Additionally, you could use CPT^® codes 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient …) for the initial day of care if the patient is admitted for observation.

Remember: If the patient is admitted to observation or inpatient care and discharged on the same date less than eight hours later, you would use either 99221-99223 or 99218-99220 without a discharge code. If the stay is greater than 24 hours, than you would use the appropriate discharge code from either 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (…more than 30 minutes) for inpatient status discharge and 99217 (Observation care discharge day management…) for observation status discharge on the discharge date.

Be sure to always verify the admission level of care to choose the correct code category, and don’t forget — these specific guidelines pertain to Medicare patients. Check with your other payers to determine appropriate coding in these scenarios.