Pulmonology Coding Alert

Remember that inpatient E/M rules won’t change in 2021.

Most pulmonology coders have spent hours poring over the changes scheduled to impact outpatient E/M codes in January, but that doesn’t mean your inpatient E/M coding can fall to the wayside. In reality, your hospital-based E/M visits must be coded the same way as always, and it’s a good idea to give yourself a quick refresher on how to report these services.

We’ve rounded up some frequently asked questions about 99221-99223/99231-99233 (Initial/ Subsequent hospital care, per day, for the evaluation and management of a patient …) and 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient …). Check out the answers to these questions so you can ensure that you’re coding and documenting properly.

Question: When Should I Use 99221-99223 vs. 99234-99236 for Initial Inpatient Care?

Answer: “The basic difference between the codes is that 99234-99236 represent the services of an initial hospital service and a discharge service performed on the same calendar date,” says JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis. 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,” advises Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia.

“If the admission is greater than 24 hours, then you would use 99221-99223 for the initial day of hospital care,” Miller adds. You also report 99221-99223 if the admission is more than eight hours, but spans two calendar days.

Question: When Can I Bill for Hospital Care?

Answer: Knowing which provider can, and cannot, bill these codes is a typically problematic issue with inpatient care. But one easy way to break it down is to remember that, “for the inpatient initial visits, only one physician can be the admitting physician and only the admitting physician can use codes 99221-99223. For Medicare, the admitting service is identified with modifier AI (Principal physician of record). All other providers should bill the inpatient E/M codes that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient consultation),” according to Miller. In the case of Medicare, consultants will not be able to report 99251-99255. Consultants are required to use 99221-99223. Consultant services to Medicare beneficiaries are identified by the lack of modifier AI.

Regardless of the service type, only one claim can be reported per patient per specialty per patient per day. This will become most important for subsequent hospital care services. For example, “if Provider A sees the patient in the morning and Provider B, who is covering for A, sees the same patient in the evening, the notes for both services are combined and only one subsequent hospital visit is coded. However, if two physicians see the patient and they are in different specialties and are seeing the patient for different reasons (i.e., different diagnosis), then both may bill a subsequent hospital visit based on that physician’s note and the medical necessity of the service,” Miller adds.

Question: How Should I Document Hospital Care?

Answer: First, these codes require you to document the three key components of history, examination, and medical decision making (MDM) appropriate to their levels have been met.

Coding alert: Remember that unlike the office and outpatient E/M codes, this will not change in 2021, and you will not be able to choose the level of hospital care based on MDM alone.

Next, in addition to a statement of the total time for the care, “documentation in the medical record should include personal documentation by the billing provider indicating presence and face-to-face services were provided and admission and discharge notes written by the billing provider,” says Miller.

Additionally, “because 99234-99236 represent both observation and hospital services, the documentation should support both services. That’s why I refer to these codes as ‘the combo codes,’” Wolf adds.

Question: What Does, and Doesn’t, Count for Time?

Answer: You are able to code your inpatient visits based on time, but this can lead to some problems when reporting the codes. “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,” notes Wolf. Inpatient E/M time-based claims also require that more than 50 percent of the total visit time is spent counseling.

Another important thing to remember is the typical time for each code is different, as the following chart shows: