Orthopedic Coding Alert

E/M Coding:

Song Remains the Same for Hospital Care Coding

Published on Thu May 06, 2021

Use 1 set of codes for initial hospital care.

If you’ve been swept up in the changes surrounding the revised office/outpatient evaluation and management (E/M) codes in 2021, you’re to be forgiven. It’s big news, and there seems to be more to find out about the ever-evolving rules on a weekly basis.

Amid all the hoopla, however, coders should understand that the other E/M services have the same rules and descriptors in 2021 that they had in 2020 — and 2019, and 2018, etc.

This includes hospital care codes, which you’ll continue to utilize in the same way you always have. The difference this year is keeping these E/M rules straight while mastering the new office/outpatient rules. Check out this quick rundown of hospital inpatient coding, so you don’t fall out of practice coding your other E/Ms.

Use These Codes 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 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.

Use Separate Code 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.”

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)
These codes include:
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.