Coding Clinic 99221/99218/99234

I completed my clinics on in patient hospital follow up visits 99231, 99232 and 99233. These three codes accounted for just over 50 of all my individual encounters for 2007. If you can get a grasp of these three, you are 1/2 way there to being a coding guru. Next up is the low level admission code 99221. This is a full admission code. The rules that apply to this code are the same that apply to the observation admission code 99218 and the same day admission/discharge code 99234. The elements in your admission note for all three of these codes are the same, which is nice, because if you master this set of rules, you master 3 codes at the same time. In 2007, I had a total of 315 admission codes (99221-99223). Only 7 of them were 99221. Of 50 observation admission codes (99218-99220), only 6 were 99218. The vast majority of patients that we take care of are sick enough that they qualify for high level admission 99223. The 99221 is not a highly utilized code by myself but I will explain the details on how to code a 99221 without being accused of fraud by the Medicare National Bank. As usual, read the following:

Before we begin read my Happy Lawyer statement in my side bar. If you still don't understand it, let me say it in easier terms.

Nothing I say here means Jack. I am not a licensed coding compliance officer. Even if I was, what I say doesn't matter since I'm not the one paying your bills. The Medicare National Bank owns your paycheck, so you have to do what they say. It doesn't matter if I'm right or not. My interpretations are based on my understanding of the Evaluation and Management Guidelines of 1995 and1997. As of November 2005, until further notice, carriers have been directed to use these guidelines in their reviews. If you disagree with my statements, you will be tarred and feathered. With that said We will start the coding clinic series with CPT code 99221

How does the AMA define a 99221?

Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.

30 minutes huh? In my state Medicare pays a 99221 about $80. That works out to $160 an hour, before overhead expenses. In fact, that is less than a high level follow up visit 99233. You already know my postition on these insulting payment rates.

Since I use this code rarely, I have not developed a card that I carry around with me, but really the rules are quite simple. Because I know exactly what qualifies for a level 3 admit. Almost all of my patients that would meet level 2 (99222) would meet a level 3 admit (99223). Last year I billed a total of ZERO level two admits. Why? Because, if they qualify for a 2, they qualify for a three. I know if my patient doesn't qualify for a level 3, it has a 99% chance of being a level one admit (99221). See how easy this is? Well, the following is the exact bare minimum you must do in order to qualify for a low level admit code 99221 and ward off the fraud police. These rules also apply to the observation code 99218, and the admit/discharge same day code 99234. (These other two codes are dependent more on utilization review rules and whether the patient's stay crossed over a calendar day. I can get into that at another time. So here it is. The 99221. You need history, physical AND decision making to qualify in their respective levels, unlike hospital follow up visits that need just 2 out of 3 areas.

History (You need all three of these components)

1. 4 elements of the HPI (character, onset, location, duration, associated signs etc. OR the status of 3 chronic medical conditions. AND
2. 2 review of systems. AND
3. 1 area from Past Medical, Medications, Allergies, Family, Social history

AND

Exam

1. Extended exam of the affected body area and other symptomatic or related organ systems OR 6 areas (2 bullets each) OR 2+ areas (12 bullets total). Documenting three vitals is considered a bullet

AND

Decision Making

1. One diagnosis is all you need. No data and minimal risk (see my previous coding entries in the side bar if you need an explanation). What it comes down to is one diagnosis. You need nothing else. I would hope if a patient is being admitted, they have one diagnosis you are prepared to bill for.

So here is a level one admission 99221, a code I billed for 7 times in an entire year.

C/C: My leg is red

HPI

28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema.

PMH

Smoker

Exam

120/80 85 102.7 temp, well appearing

heart: RRR without murmur, good femoral pulses

lungs: clear to auscultation, normal effort

abdomen: soft, no palpable liver

Skin: erythema lines marked and noted, induration present

Musculoskeletal: normal ROM knee, no clubbing, cyanosis

Labs

none. No xrays

Impression

1. Cellulitis

Plan

IV antibiotics.

That's all you need folks. A very straight forward admission. If I have a young person with no xray data or EKGs or anything that I personally interpret or a very straight forward problem, It is a level one admission. But these are rare. Very rare.

Several notes. On physical exam, you can write "normal" and it constitutes a full exam of that body area. You cannot write "abnormal" I can't think of any other real reasons a level one admission would be necessary, unless you discharged them 3 hours ago and they come back to the ER to be readmitted. And even then, the complexity can often bump you into a level 3 admission all over again. As far as the 99218 (lowest level observation admission) and a 99234 (lowest level admit/discharge same day), these codes follow the same rules for evaluation. It's just that the calendar timing is different. If a patient passes midnight in their stay and they are observation status, use 99218. If they discharge the same calendar day (don't spend a midnight), use 99234. If you are going to use the same day codes 99234-99236, remember they have to be in the hospital for at least 8 hours or nobody gets paid.

Next up, 99222, a code I billed a total of ZERO times last year.

Happy Coding.