Urology Coding Alert

Break down the key features of each respective code range.

Hospital-based evaluation and management (E/M) coding isn’t exactly a staple of urology coding, but that’s all the more reason to be well versed in the coding mechanics for the off-chance a case hits your desk. From initial inpatient care to subsequent inpatient hospital care or observation care, there are plenty of variables to take into account if you want to ensure you’ve reached the right code.

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 (Observation or inpatient hospital care, for the evaluation and management of a patient …) represent the services of an initial hospital visit or observation care 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 include both the admission and discharge on the same date as well as reflect the exact times for admission and discharge.

“To bill 99234-99236, you must have a statement that shows the stay for inpatient hospital care or observation 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 lasts more than 24 hours, consider using 99221-99223 (Initial and Subsequent hospital care, per day, for the evaluation and management of a patient …) for the initial day of hospital care. However, there are instances where a patient can be in observation for up to 48 hours, in which case you’ll report code range 99218-99220 (Initial observation care…) for the admission alongside 99217 (Observation care discharge day management …) for the discharge.

Remember: The patient can be in an inpatient bed, but still be considered in observation care as an outpatient in some instances. Furthermore, the place of service (POS) will always be 22 (Outpatient hospital) for observation care as these patients are never considered inpatients.

Question: When Can I Bill for Hospital Care?

Answer: Knowing which provider can, and cannot, bill these codes is a common problem 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.

For a consultation, you cannot report 99251-99255 (Inpatient consultation for a new or established patient …) to Medicare, though some other payers will still want you to use those codes. For Medicare, report 99221-99223 without modifier AI.

Regardless of the service type, only one claim can be reported per patient, per specialty, per day. This is 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 documentation supporting certain levels of the three key components of history, examination, and medical decision making (MDM).

Coding alert: Remember that unlike the office and outpatient E/M codes, this does 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 were written by the billing provider,” says Miller.

Additionally, “because 99234-99236 represent both observation and hospital services, the documentation should support both services, when applicable. 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 can code your inpatient visits based on time, but first ensure the documentation supports time-based coding. “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 may be 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:

Question: Can I Bill for a Related Office and Outpatient E/M Alongside the Initial Hospital Visit?