99222, 99219, 99235 CPT® Code Descriptions, Progress Note, RVU, Distribution.

This 99222, 99219 and 99235 CPT® lecture reviews the procedure code definitions, national distribution data, RVU values and progress note requirements for the mid level initial hospital service encounter. CPT stands for Current Procedural Terminology. I have chosen to discuss these three codes together because their coding guidelines are identical with regards to determining the level of service provided. What is the difference between these three initial hospital service encounter codes? CPT® 99222 is the mid range (level 2) initial inpatient H&P encounter code. CPT® 99219 is the mid range (level 2) initial observation H&P encounter code used only by the attending physician or non-physician practitioner (NPP). CPT® 99235 is the mid range (level 2) admit and discharge same day bundled encounter code used only by the attending physician or NPP. CPT® 99235 can be used in both inpatient and observation same day admit and discharge scenarios.  Before the level of service can be decided, understanding which group of initial hospital encounter codes are appropriate is required. 

CHOOSING THE CORRECT INITIAL HOSPITAL SERVICE CODE GROUP


All three of these initial hospital encounter codes represent the middle level of service under the Healthcare Common Procedure Coding System (HCPCS) for initial inpatient, observation and admit and discharge same day bundled hospital encounters. Before physicians and NPPs can choose the right level of CPT® service (low, medium or high), they must first understand which group of CPT® codes apply in their initial hospital service encounter (inpatient, observation, same/day admit and discharge, critical care). For readers who need further help in determining the correct group of codes to consider for their admission, I refer them to my post on choosing the right CPT® code for hospital admission. At that lecture, I help guide the physician and other NPPs through a series of questions that help them determine which set of initial hospital encounter codes apply to their patient's situation. This process can become quite complex. Understand it well before proceeding with this coding lecture. Once the correct group of codes are determined, the practitioner can determine the correct level of service. The rest of this lecture describes the the level 2 (middle) initial hospital service encounter codes 99222, 99219 and the bundled admit and discharge same day code 99235.

The level 1 admission for inpatient, observation and same day admit and discharge hospital codes (99221, 99218 and 99234 respectively) and the level 3 admission for inpatient, observation and same day admit and discharge hospital codes (99223, 99220 and 99236 respectively) are described elsewhere on The Happy Hospitalist as part of my complete collection of CPT® lectures. I am a board certified internist and hospitalist with over ten years of clinical experience with a  community hospitalist program at a large hospital system. I have written an extensive collection of evaluation and management (E/M) lectures over the years to help physicians and NPPs (nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives) understand the complex world of hospital and clinic based evaluation and management coding requirements. Some of these lectures were written several years ago, but their information remains highly relevant today.

Once the clinician has chosen the correct group of initial hospital care codes, the right CPT® level of service that documentation supports should then be defined. The rest of this coding lecture details the requirements for the mid level initial encounter codes. For the purposes of simplicity, the billing requirements for 99223 = 99220 = 99236. The billing requirements for 99222 = 99219 = 99235. The billing requirements for 99221 = 99218 = 99234. This is why I have chosen to bundle these three initial hospital service CPT® evaluation codes together for discussion.

My collection of lectures and accompanying coding resources are used by myself to make sure I stay compliant with the rules and regulations of the Centers for Medicare & Medicaid Services (CMS). All CPT® lectures I have written are organized in one easy-to-find location at this link. Always remember that it is the responsibility of the billing clinician to make sure their documentation supports their  level of service they are submitting for reimbursement. The volume of chart documentation written in the chart  should not be used to determine the level of billed service. What matters most are the details of the documentation as defined by the rules discussed in this and other CPT® lectures. The CMS E/M services guide referenced below says the care provided must be "reasonable and necessary". In addition, all progress notes must be dated and have a legible signature or proof of signature attestation.

99222, 99219, 99235 CODE DESCRIPTIONS 


My interpretations detailed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section linked here. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard compliance audit tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different standard than that which I have presented here in my free educational discussion. I recommend all readers obtain their own up-to-date CPT® reference book as the definitive authority on CPT® coding. I have provided access to Amazon through the 2015 CPT® standard edition pictured to the right. These three CPT® codes can be used by any qualified healthcare practitioner to get paid for their hospital initial service evaluations. How does the AMA define codes 99222, 99219 and 99235?

CPT® 99222 is defined by the AMA as:
Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate 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 moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.
CPT® 99219 is defined by the AMA as:
Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling an/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 to "observations status" are of moderate severity.  Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit. 
 CPT® 99235 is defined by the AMA as:
Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate 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 presenting problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.
From the descriptions detailed above one can see the requirements for CPT® 99222, 99219 and 99235 are identical, including the expected typical time spent of 50 minutes. This is why these three codes can be grouped together when discussing the E/M guidelines we have been given to stay compliant with CMS rules and regulations. These codes can be billed based on time under certain circumstances. I have detailed those discussions at the provided link. Documentation of time is not a required component to stay compliant with CMS rules. If billed without time as a consideration, these three codes should be billed based on the documentation rules detailed in the 1995 or 1997 guidelines referenced above. The three relevant components to a hospital initial service care note are the:
  1. History 
  2. Physical Examination 
  3. Medical Decision Making Complexity (MDM) 
For all initial hospital encounter evaluations, the highest documented three out of three for history, physical and MDM determines the correct CPT® service code. Compare this with the highest documented two out of three components being required for hospital subsequent care encounters. Again,  the level of service for all three groupings of initial hospital encounters from 99221-99223, 99218-99220 and 99234-99236 are determined by the highest  three out of three components from history, physical and MDM.  Another way of stating this fact is to say the level of service is determined by the lowest level of documentation from any of those three areas.  If the history and MDM documentation meet criteria for a level three admit, but the physical exam documentation only meets criteria for a level 1 H&P, the level of service for the initial hospital encounter code is a level 1.  Notice I said documented and not performed.  If you don't document your work, it's considered not done.  Documentation is key to staying compliant.   The following discussion details the absolute minimum requirements required to remain compliant with CPT® codes 99222, 99219 and 99235. In addition, remember a face-to-face encounter is always required.
  • Comprehensive history
    • Requires 4 elements from the history of present illness (HPI) OR documentation of the status of three chronic or inactive medical conditions.   HPI elements are location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms.
    • Requires  documentation from 10+ review of systems.  ROS is an inventory of body systems.  The E/M rules recognize the following systems for ROS purposes:  constitutional symptoms, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (skin and or breast), neurological, psychiatric, endocrine, hematologic/lymphatic and allergic/immunologic.  Those systems with positive or pertinent negative responses must be individually documented.  For the rest of the systems, documentation that all other systems are negative is permissible. 
    • Requires documentation from  past medical history (illnesses, operations, injuries and treatments) and family history and social history (PFSH).
  • Comprehensive physical exam:
    • 1995 guidelines: A general multi-system examination or complete examination of a single organ system. The medical record for a general multi-system examination should include findings from about 8 or more of the 12 organ systems.
    • 1997 guidelines: A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).  It should include at least nine organ systems or body areas with 2 bullets in each section.  Physical exam is complex for E/M This process is thoroughly detailed in the CMS E/M reference guide (pages 31-32 for the 1995 guidelines and pages 49-81 for the 1997 guidelines)
    • Note the wordage difference with body area vs organ systems. They are not the same. This stuff is complex.  A review of the acceptable body areas and organ systems can be found in that CMS E&M reference guide on pages 31 and 32.  The recognized body areas are head (including face), neck, chest (including breasts and axillae), abdomen, genitalia (including groin and buttocks), back (including spine) and each extremity. The recognized organ systems are constitutional (including vital signs and general appearance), eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, psychiatric, hematologic/lymphatic/immunologic.
  •  Medical decision making of moderate complexity (MDM): Medical decision making  is split into three additional components, the highest 2 out of the 3 levels in MDM of which are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and the minimum required level of points and risk as defined by the Marshfield Clinic audit tool?
    • Diagnosis (3 points) 
    • Data (3 points) 
    • Risk (moderate) The table of risk can be found on page 20 of the CMS E/M reference guide.
The medical decision making point system is quite complex. I have a detailed reference to it on my E/M pocket cards described below. These cards help me understand everyday what type of care my documentation supports. I carry these cards with me at all times and reference them all day long. They help me understand what level of service my evaluation qualifies for and they have prevented me from under and over billing thousands of times over the last decade.

 

CLINICAL PROGRESS NOTE EXAMPLE OF 99222 


Here is a note for a mid level hospital inpatient initial encounter (99222), a mid level hospital observation initial encounter (99219) and a mid level same day admission and discharge bundled care code 99235. 
C/C: My leg is red
HPI:  28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema. (4 elements from HPI)
PFSH:  On no meds.  Smoker, Mother with eczema,  (All 3 elements documented)
ROS:  Except as dictated above, all other systems were reviewed and otherwise negative without further pertinent positives or negatives (10+ROS documented.  This notation is allowable under E/M rules)
Exam: 120/80 85 102.7 temp, well appearing (9 organ systems with at least 2 bullets each)
HENT:  Normal
Eyes:  Normal
CV:  Normal
Respiratory:  Normal
GI:  Normal
Psychiatric:  Normal
Lymphatic:  Normal
Neurological:  Normal
Skin:  Edema, warmth, redness right leg, lines consistent with cellulitis, marked with skin marker.
Labs/Data:  None
Impression
  1. Cellulitis (4 points for new problem, further workup planned under the number of diagnosis for medical decision making
Plan
Check doppler to rule out clot.   Start antibiotics. See orders.  (moderate risk for prescription drug management).
This patient meets criteria for a level two initial hospital encounter because it contains all the required medically necessary and reasonable elements for a comprehensive history, a comprehensive physical exam and moderate complexity medical decision making.  All required components were achieved under history and physical exam criteria.  The only difference between the level three initial admission codes and the level 2 codes are the high vs moderate complexity in MDM.  History and physical element requirements are the same.

Medical decision making in this initial encounter is moderate complexity because this patient achieved 4 points for a new problem with further workup planned under the diagnosis component and they received moderate risk based on prescription drug management for ordering antibiotics.   In this clinical example, the data component of MDM does not apply.  Since the three MDM components have a level 3 (diagnosis), a level 2 (risk table) and a level 1 or less (data), the highest two out of three qualifies the total MDM as a level two, or moderate complexity.

The risk table is an under appreciated element that can often support a higher level of service than clinicians give credit for their work. I highly recommend physicians read and understand the risk table to better understand why they are likely  under coding every day.  The point system detailed above  is part of the Marshfield Clinic audit tool I use every day with my bedside E/M pocket cards detailed below.  I have provided high clinical impact risk elements on these cards.  I use them  to make sure my billing and coding accurately reflects the level of service I provide. Why am I able to document the things I did above and have it comply with E/M rules?  I have provided a list of these and other high impact E/M coding pearls at my lecture on level 3 initial hospital care codes 99223, 99220 and 99236.  I will not repeat those details here, but I recommend all readers review them at their convenience to understand their significance as they relate to the  progress note documentation example detailed above.  For example, writing normal on physical exam elements is allowed.  So is the notation for identifying when a complete review of systems has been performed.  These and other important coding pearls are detailed in the lecture linked above. 

DISTRIBUTION OF HOSPITAL INITIAL CARE CODE 99222


What is the distribution of CPT® 99221, 99222 and 99223 for internal medicine in the country? One Medicare contract carrier actually told us the answer in a January, 2013 pdf presentation (based on January 2011 through December 2011 data). I was unable to find data on the other initial hospital care codes 99219 and 99235. Here is their analysis.
  • 99221:  about 4% of total for these hospital initial visit codes. 
  • 99222: about 28% of total for these hospital initial visit codes.
  • 99223: about 68% of total for these hospital initial visit codes.
One additional resource described the ten year trend (2001-2010) of E/M coding trends.   The OIG published a report in May, 2012 titled Coding Trends of Medicare Evaluation and Management Services.    As you can see, the proportion of 99221 vs 99222 vs 99223 has remained consistently constant over the last 10 years.  This data is for all Medicare E/M charges in this code group and not limited to internal medicine as reviewed just above.  As you can see, in 2010, 55% of initial inpatient hospital care codes were 99223, 36% were 99222 and 9% were 99221.

Initial-Inpatient-Hospital-Care-10-Year-Coding-Trend-Table-2001-2010

In the same resource (on page 23), the OIG also published ten year E/M coding trends for the initial observation admission codes 99218-99220 and the admit and discharge same day codes 99234-99236.    This data is not exclusive to internal medicine.  A trend toward submitting higher intensity of service was observed with increases in the highest level in the code group and decreases in the others.  The national distribution for  initial observation care codes in 2010 was 54% for 99220, 36% for 99219 and 11% for 99218.  For the admission and discharge same day codes, the 2010 data data showed the proportions as 40% for 99236, 41% for 99235 and 19% for 99234.

Admission-And-Discharge-Same-Day-Care-10-Year-Coding-Trend-E/M-Table-2001-2010-OIG


How often are CPT® codes 99222, 99219 and 99235 billed to Medicare?  Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99222, 99219 and 99235 encounters were billed and the dollar value of their services for Part B Medicare.
  • 99222
    • Allowed services - 7,506,127
    • Allowed charges - $1,002,020,918.93
    • Payments - $784,273,298.43
99221-99223 National Procedure Summary File CMS 2011
  • 99219
    • Allowed services - 418,376
    • Allowed charges - $44,551,280.28
    • Payments - $34,236,602.35
99218-99220 National Procedure Summary File CMS 2011
  • 99235
    • Allowed services - 151,616
    • Allowed charges - $26,176,429.56
    • Payments - $20,230,812.12
99221-99223 Medicare Part B National Procedure Summary File 2011



RVU VALUE 


How much money does a CPT ® 99222, 99219 and 99235 pay in 2014?  That depends on what part of the country you live in and what insurance company you are billing.    All CPT® codes are paid in relative value units (RVUs).  I have previously discussed the complex nature of RVUs.    Here are the raw RVU values and their dollar value in my geographical area:
  • 99222:  Work RVU 2.61.  Total RVU 3.87.  Dollar value of about $130
  • 99219:  Work RVU 2.60.  Total RVU 3.80.  Dollar value about $129
  • 99235:  Work RVU 3.24.  Total RVU 4.74.  Dollar value about $160.
I have provided a complete list of RVU values on common hospitalist E/M .  The 2014 RVU dollar value conversion rate is 35.8228.  I have my entire collection of E/M lectures organized here.  I've tried to make this complex process as simple as possible to help others understand how important documentation is to stay compliant and to get appropriately paid for the work they are providing.  It took me years of daily diligence and carrying my E/M pocket reference card around  with me at all times to get comfortable with medical billing and coding.  Remember, what code you bill is entirely dependent on how you document, not how much you document.


LINK TO HOSPITALIST POCKET CODING CARD POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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