Orthopedic Coding Alert

Question: Encounter notes indicate that on Jan. 2, 2023, the provider performed initial observation care for a patient that involved a comprehensive examination and history along with moderate-level medical decision making (MDM). Total encounter time was 48 minutes. How should I report this encounter?

Nebraska Subscriber

Answer: Since you’re coding in 2023 now, you will be using the new guidelines for reporting hospital observation services. That means when choosing a code, you don’t have to notes the levels of exam or history.

You will, however, focus on MDM and time — because you can code using either. In this case, you should code based on MDM as it will result in a higher-level code.

On your claim, use MDM as the deciding factor and report 99222 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.).

If you had coded using time instead, you would have to choose 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.).