Primary Care Coding Alert

Question: How do we discern which codes to use for patient hospital admissions, stays or discharges that take an abnormally long time? Are there special allowances for these time-consuming events? Are there certain modifiers that should be used?

Anonymous MI Subscriber

Answer:

1. Same day as admissions.

As far as long admissions are concerned, Patricia A. Trites, CPC, president of Battle Creek, MI-based Healthcare Compliance Resources, a healthcare compliance company, says to use 99221-99223 (initial hospital care, per day levels, ranging from detailed to comprehensive histories, detailed to comprehensive examinations and straightforward to high complexity decision-making) as long as documentation supports the particular level of service. The more complex and time-consuming the visit is on the day of admitting the patient to the hospital, the higher the level coded.

Even if the patient is admitted from the emergency department, the family practitioner should use these hospital admission codes, she explains. All of the services that are provided by the physician in conjunction with the admission are considered part of the initial hospital care code when performed on the same date as the admission.

In determining which level to use, CPT 2000 adds: The inpatient level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites as well as in the inpatient setting.

2. After admission.

When the family doctor spends an extended period of time (up to an hour) with a patient in the hospital setting after the day of admission, it requires the use of 99356 (prolonged physician service in the inpatient setting requiring direct patient contact beyond the usual service; first hour). Service may be intermittent on the same day, and as long as the total is between 30 and 60 minutes, 99356 is used. Prolonged services may be billed along with other appropriate E/M codes for inpatient service such as 99231-99233 (subsequent hospital care, per day, depending on the complexity of the history, examination and decision-making).

Tip: Less than 30 minutes is not coded separately because it is included in the E/M code.

If the family practitioner stays for an hour-and-a-half, for instance, he should code 99357 (each additional 30 minutes) in addition to 99356. If the visit was two hours, then 99357 should be coded twice, again in addition to 99356. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final half hour is not reported separately.

If the prolonged physician service with direct contact is continuous and the services exceed the highest level of service (99233, subsequent hospital care, per day, including a detailed interval history and examination and decision-making of high complexity), modifier -21 (prolonged evaluation and management service) should be added to the E/M code.

For example, a 62-year-old male with chronic obstructive pulmonary disease and bronchospasm was initially admitted to the hospital for acute respiratory distress requiring a ventilator in the intensive care unit. Once stabilized, he is transferred to the floor but then develops acute fever, labored breathing, evidence of carbon dioxide retention, insufficient oxygenation of the blood and a secretion in the bronchial tube.

The family practitioner spent a continuous 90 minutes examining the patient, assessing his condition and counseling both the patient and his family. Since the service exceeds the highest level of E/M, the family doctor should code 99233 with modifier -21.

3. Discharge.

If the discharge process takes 30 minutes or less, you should use 99238 (hospital discharge day management, which includes, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms). If the discharge procedure is longer than 30 minutes, use 99239.