Pulmonology Coding Alert

Question: Our physician saw a COPD patient in the hospital at the request of the hospitalist. The pulmonologist’s notes were not complete but he did note that he spent 36 minutes on the encounter and he documented what he discussed with the patient and his family. Can we bill the inpatient code based on the time spent?

Arkansas Subscriber

Answer: Because 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components…) is the highest level of subsequent hospital care, documentation typically requires two of these three criteria: A detailed history, detailed exam, and/or high-complexity medical decision-making (MDM). However, you can also report 99233 based on time if you meet the documentation requirements. CPT^® assigns a 35-minute time threshold to this code. Although many coders think of time-based E/M coding only as an outpatient strategy, it’s perfectly acceptable to use time as your overarching code selection criteria in the inpatient setting, if you meet the guidelines.

Ensure that the following three factors are documented in the hospital record if you select 99233 based on time:

1. The total time spent with the patient (which should be at least 35 minutes for 99233)
2. The time spent counseling/coordinating care (which must exceed 50 percent of the total visit time)
3. A description or summary of the counseling/coordination of care provided.

Keep in mind that the total time for an inpatient is considered as the face-to-face time plus the unit/floor time spent in care directly related to the patient.

For instance, “Saw the patient for 35 minutes face-to-face; 20 minutes of that visit was spent counseling the patient and her daughter about her COPD diagnosis, potential treatment options and prognosis; answered multiple questions and provided them with educational information.”

In your question, you note the total time spent and what was discussed, but there’s no indication that the physician spent at least half of that time on counseling/coordinating care. If you do have the time spent in counseling/coordination documented in the record, then you can bill based on time, but if you only have a record of the total time spent, you probably can’t report this code unless you have something in writing from your payer indicating it’s allowable.