Urology Coding Alert

E/M Coding:

Look to These 5 Tips to Improve Your Inpatient Coding

Published on Tue Mar 12, 2024

Keep up with changes in hospital E/M codes.

Over the past year, you have been employing an updated series of codes to record hospital admissions, observation care, and evaluation and management (E/M) services related to same-day observation and discharges.

The revisions have enabled you to use the same medical decision making (MDM) elements, with the exception of a few elements added to the table from 2021 to 2023 that CPT^® introduced in 2021 for the office/outpatient E/M services, to determine appropriate service levels. You’ve also been using revised time parameters for determining those service levels, when applicable.

So, this is a good moment to review the codes and make sure you’ve been applying them correctly. Here are five things you should be doing any time your urologist admits a patient for inpatient care and provides services for them during their stay.

1. Know These Key Definitions Before Reporting Initial Services

At the end of 2022, CPT^® deleted the initial, subsequent, and discharge observation service codes (99218-99220, 99224-99226, and 99217, respectively) and rolled observation services into the new initial and subsequent inpatient care service codes. The initial service codes are as follows:

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)

99222 (… moderate level of medical decision making … 55 minutes must be met or exceeded)
99223 (… high level of medical decision making … 75 minutes must be met or exceeded)

Before using one of these codes, you should consider the following definitions:

Per day means the “total time on the date of the encounter … by calendar date” according to CPT^®. A visit spanning two calendar dates is “a single service and is reported on one calendar date,” even if the services are continuous beginning on one calendar date and extending through midnight into the next. In the 2024 CPT^®guidelines, the AMA clarifies that “per day” means you should report a single code when a patient has multiple visits on the same calendar date and in the same setting. The guideline goes on to state, “when using MDM for code level selection, use the aggregated MDM over the course of the calendar date. When using time for code level selection, sum the time over the course of the day using the guidelines for reporting time.”

Observation means “ongoing short-term treatment, assessment, and reassessment, furnished while a decision is being made regarding whether a patient will require further treatment as a hospital inpatient or if they are able to be discharged from the observation care.” It generally does not exceed 24 hours, and “only in rare and exceptional cases do outpatient observation services span more than 48 hours,” according to a Novitas observation care fact sheet.

Place of service (POS) “should identify the patient’s location,” according to the Novitas fact sheet. As the Centers for Medicare & Medicaid Services (CMS) regards observation services as outpatient services, this means using POS code 22 (On campus — outpatient hospital) for Medicare claims that are solely for outpatient services. If the observation services turn into an inpatient admission, you should use POS code 21 (Inpatient hospital).

2. Know When to Report Subsequent Services

Once a patient has “received any professional services from the physician or other qualified health care professional [QHP] or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation … admission and stay,” per CPT^® guidelines, you can assign one of the following codes for subsequent inpatient care per day:

99231 (Subsequent hospital inpatient or observation care, per day … which requires a … straightforward or low level of medical decision making. When using total time … 25 minutes must be met or exceeded)

99232 (… moderate level of medical decision making … 35 minutes must be met or exceeded)
99233 (… high level of medical decision making … 50 minutes must be met or exceeded)

CPT^® also considers “advanced practice nurses [APNs] and physician assistants [PAs]” as “working in the exact same specialty and subspecialty” when they work together with a physician.

3. Know How to Report Same-Day Admission and Discharges

To report inpatient care services for a patient admitted then discharged on the same day, you know to use one of the following:

99234 (Hospital inpatient or observation care… including admission and discharge on the same date, … straightforward or low level of medical decision making. … 45 minutes must be met or exceeded)
99235 (… moderate level of medical decision making … 70 minutes must be met or exceeded)
99236 (… high level of medical decision making … 85 minutes must be met or exceeded)

However, the trick to assigning one of these codes for Medicare, or those following CCMS rules, lies in documenting how long the patient stayed in the facility. “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. If the admission is greater than 24 hours, then you would use 99221-99223 for the initial day of inpatient hospital care,” advises Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia.

4. Know How to Report Discharges

You’ll document discharge services administered by your provider or QHP with one of the following time-based codes:

99238 (Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter)
99239 (… more than 30 minutes on the date of the encounter)

But you’ll need to make sure you follow these CPT^® guidelines before you do:

Document all patient services provided on discharge day, including the provider’s “final examination of the patient, discussion of the hospital stay, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions, and referral forms.”
Do not report in conjunction with initial hospital inpatient or observation care service codes 99221, 99222, 99223. Instead, you’ll use 99234, 99235, or 99236 as appropriate for discharges on the same day as admission.
Report only those services provided by the physician or QHP responsible for discharge. If other providers render services on the date of discharge, they should report the appropriate code from the subsequent category.

5. Know How to Count Time Correctly

Finally, if you document any of these codes by time, remember this advice: “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 JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.