Urology Coding Alert

Brush up on your inpatient know-how with 4 everyday scenarios.

Coding for hospital E/M services is quite different from office visits, with some nuances all its own. Reporting E/M services in a hospital setting can be especially tricky for some coders, and even the providers.

“There is an extreme need for physicians and their coding staffs to constantly work on understanding the E/M coding process, particularly the necessary supporting documentation,” says Duane C. Abbey, PhD,  president of Abbey and Abbey Consultants Inc., in Ames, IA.

Help is here: Read on for real-world scenarios and solutions that will help you report your physician’s services accurately.

Scenario 1: Capturing the Admission Code

Question: The urologist admits a patient to the hospital and asks you to report the admit code for the service. What do you report?

Answer: CPT^® 2017 does not include a code specifically for hospital admission, even though physicians often document that they performed an “admit.” Since there’s no clear-cut code, choose from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) if the urologist documents the elements contained within the codes (appropriate history, exam, and medical decision-making).

Tip: The physician is not billingfor the admission itself. He’s billing for the care that he initially provides, based on the documentation.

CPT^® states that the initial hospital care codes “are used to report the first hospital inpatient encounter with the patient by the admitting physician.”

“Note also that the date of admission in the hospital record may be different from the initial hospital care that a physician provides,” cautions Abbey. “A patient may present through the ER late in the evening, but the attending physician may not see the patient until the next morning. Obviously, the nuance between admission and initial care can create compliance issues.”

Scenario 2: Assigning Modifiers for Same Day E/M and Surgery

Question: The surgeon completes an initial hospital E/M service and then performs surgery on the same patient within the next few hours. Should modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) be appended to the E/M code or should one append modifier 57 (Decision for surgery)?

Answer: If major surgery, such as a nephrectomy for a traumatic kidney injury, immediately follows a hospital E/M service, you should append modifier 57 to the inpatient E/M code to differentiate it from the usual preoperative exam included in the global package. If, however, the surgery is a minor procedure, such as the placement of a ureteral stent to bypass an obstructing ureteral stone, then the 25 modifier would be the appropriate choice.

“Note that the 57 modifier applies to what Medicare classifies as major surgeries[i.e., 90-day post-operative period] as identified in the Medicare Physician Fee Schedule [MPFS] as delineated in RBRVS [Resource-Based Relative Value Scale],” says Abbey.

For private payers who refuse to pay for an E/M service with modifier 25, try appending modifier 57 to the associated E/M service in place of modifier 25, advises Michael A. Ferragamo, MD, FACS, assistant clinical professor of urology with the State University of New York, University Hospital and Medical School at Stony Brook.

Scenario 3: Reporting Discharge After Seeing Multiple Providers

Question: Suppose a patient has a complex health history, and is therefore under treatment from four different practices simultaneously. When one of the practices bills the discharge code, it gets denied. You learn that one of the other practices billed for the service first. Should that practice’s provider split the payment with the other physicians?

Answer: Several physicians might be managing the care of a patient, and all might try to bill for the discharge—but only the main attending physician should collect for it, CMS indicates.

MLN Matters article MM5794 notes, “Only the attending physician of record (or physician acting on behalf of the attending physician) shall report the hospital discharge day management service (CPT^® code 99238 or 99239).” Any other physicians should instead report a subsequent hospital care code (99231-99233) for a final visit with the patient.

Caution: Keep in mind that sometimes a patient may not be eligible for a discharge code. This can happen in various circumstances, such as if the patient never left the emergency room and thus was never admitted as an inpatient. In this case the physician would report an ED service code (99281-99285).

“See also the AI modifier (Principal physician of record) that identifies the principal physician of record,” adds Abbey.

Explanation: Modifier AI indicates the service by the admitting or attending provider who oversees the patient’s care, as distinct from other providers who may furnish specialty care. The principal provider of record should append modifier AI to the initial visit code.

Scenario 4: Know What ‘Intensive Care’ Really Means

Question:  The urologist sees a patient in the intensivecare unit (ICU). He circles critical care code99291. Do all of his services become critical care services just because the place of service is the ICU?

Answer: No, you cannot bill the critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes [List separately in addition to code for primary service]) simply because the place of service is the ICU.

Why not: Critical care is not based on the location of service. Instead, the term describes a type of care. The physician must meet three criteria before billing for critical care:

• The patient must have a critical illness or injury (usually defined as a critical organ system failure or a shock-like syndrome with a high probability of imminent or life threatening deterioration in the patient's condition)
• The physician must document at least 30 minutes of time spent directly with the patient or in the hospital unit, limited only to that patient.
• The physician must document highly complex decision making to assess, manipulate, and support vital system function(s) to treat the critical illness or to prevent further deterioration of the patient's condition.

Better option: If your physician evaluates a patient in the ICU but does not perform critical care services, you’ll report an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...) or an appropriate subsequent hospital care code (99231-99233).

“Note that the time the physician spends with a given patient may not be continuous, that is, the physician may spend 20 minutes, leave, and then come back and provide services for say another 15 minutes,” says Abbey. “This time can be accumulated, but documentation of the time and type of services becomes critical. See also the need to distinguish between services such as CPR (cardiopulmonary resuscitation) and critical care.”

Final takeaway: “E/M coding for physicians and practitioner for services provided in the hospital setting can be confusing and complex,” admits Abbey. “Physicians, as well as coding staff, need to be constantly vigilant to make certain that the documentation provided supports the E/M coding. Coding staff should and must work with physicians to improve documentation when problematic situations arise.”