This is my coding lecture on how to bill the mid level hospital in-patient admission, observation admission and same day admit/discharge evaluation and management (E/M) codes. These are CPT® codes 99222, 99219 and 99235 respectively. What do these codes represent and why can I group them all together in one free coding lecture? All three codes have the exact same documentation requirements. Deciding on which code to use is dependent on what the status of the patient is with regards to their hospital admission. Just answer this two questions:
Is the patient inpatient or observation status and is their admit and discharge on the same or different calendar day (using midnight as the cut off)?
Once you answer these two questions (which your utilization review folks need to help answer for you) you can figure out which group of codes to use and then, using my teaching here, decide if your codes meet criteria for these mid level E/M CPT® billing codes. I'm going to spend a little time here explaining when to use each group of codes, then I'll tell you how to meet the basic minimum requirements necessary not to be accused of Medicare fraud when billing these codes.
CPT® 99222 is the mid level hospital admission code we use for our initial visit if the patient is considered in-patient status. In addition to billing critical care codes CPT® 99291 and 99292 on admission, the only three evaluation and management codes we can use for the initial in-patient hospital admission process are CPT® 99221-99223. Which code you pick is dependent on what your documentation supports. Last year, CMS stopped paying for all in-patient consultation codes (CPT® 99251-99255). What does that mean for physicians caring for Medicare patients? All physicians, attending and consultative, should be using CPT® codes 99221-99223 on their initial in-patient evaluation.
CPT® code 99219 is the mid level initial evaluation visit used for patients under observation status in the hospital. The choices here are 99218-99220. Which code you pick is dependent on what your documentation supports which I will teach you below. Unlike the inpatient codes above, only the attending physician (known also as the admitting physician) can use this code for the initial visit during an observation admission. Consultants who have been asked to see an observation patient should be billing the outpatient consultation codes, CPT® 99241-99245.
But here is where it gets complication. Medicare no longer recognizes any consultation codes, including outpatient consultation codes 99241-99245. Therefore, physicians who are seeing Medicare patients as consultants during a hospital observation stay should be billing the new patient outpatient evaluation codes 99201-99205.
However, here is where it gets even more complicated. If that Medicare patient has been seen anytime in the last three years (even one time) by anyone in your group of physicians, you cannot bill a new patient outpatient evaluation for that patient in the hospital under observation status. You must bill the established outpatient follow up codes (CPT® 99211-99215), even if you've never seen the patient before. Basically, all you can bill for is a progress note, the lowest of low in terms of reimbursement, even if you've never seen the patient before. And if you don't even submit the right code, you won't get paid at all! I'm sure very few physicians understand this complicated differential diagnosis of their billing decision tree.
As you can see, this whole evaluation and management (E/M) process borders on comedy if physicians weren't at risk for being thrown in jail and fined tens of thousands of dollars every time they billed the wrong code for the wrong status. This is the tens of billions of dollars your government considers waste and fraud. These are honest physicians trying to figure the whole thing out and getting it wrong because the rules make getting it right nearly impossible.
The last set of mid level codes fall into the inpatient or observation admit and discharge same calendar day category. The three possible codes here are CPT® 99234-99236 admit/discharge same calendar day (using midnight-to-midnight as the cut offs). Again, these codes shall only be used by the admitting/attending physician and not a physician evaluating the patient in consultation. Which code you choose is dependent on what your documentation supports which you will learn by continuing your coding journey to the bottom of this post.
You've come this far, why stop now? You're almost there! Here is my understanding of these three codes. Find out what calendar day your hospital has listed as the day the patient is admitted observation or in-patient status. If the day they are admitted is the same calendar day you discharged them, the attending physician must use either CPT® 99234, 99235 or 99236 as the global admit and discharge physician evaluation and management code. No other E/M codes can be billed for the hospital stay. These are a global admit and discharge code for both in-patient and observation stays. But make sure the patient spends at least eight hours in the hospital, because Medicare won't pay the hospital or the doctor for any work if you discharge the patient before eight hours. The solution is simple. Round on them last and take an extra long lunch break if you have to.
CPT® 99234-99236 apply to patients whether they are observation or in-patient status. Occasionally I will do a full in-patient admit and discharge on the same day using a critical care code as my admission billing code (drug overdose on the ventilator that is admitted at 1 am and discharged at noon on the same day). In these situations I will bill a critical care code 99291 on admission and a discharge code CPT® 999238 or 99239 for discharge on the same calendar day, which goes against everything I've been taught with regards to getting paid for an E/M code performed after a critical care code, on the same calendar day.
I'm beginning to believe, however, that I could use the add on critical care code 99292 to get paid for discharge work provided since most payers won't pay for an E/M code after a critical care code, but will pay for the add on code 99292 when used in conjunction with a 99291. However, it gets more complicated when one considers the 99292 might be billed by a physician other than the doctor who billed the 99291 and may or may not get paid either. This situation is certainly not common but can occur with occasional frequency in the right patient population.
So hopefully you've got the basics down. Is the patient's admit and discharge on the same calendar day using midnight at the cut off marker? If so, use CPT® codes 99234-99236 for your global admit/discharge code, but make sure the patient lingers for at least eight hours by rounding on them last and taking an extra long lunch break if you have to. Once you've determined that the patient's admit and discharge date fall on different calendar days, determine if the patient is in-patient or observation status. If the patient is inpatient status, choose CPT® 99221-99223 as your initial evaluation code. You will eventually bill a 99238 or 99239 for the discharge code. If the patient is observation status chose CPT® 99218-99220 as your initial evaluation code of choice. When you eventually discharge the patient, the only code available is CPT® 99217.
Now for why you're here. What are the bare minimum requirements necessary to meet Medicare muster for billing a CPT® 99222, 99219 or 99235 evaluation and management initial admission code? Before I explain, read my disclaimer:
I am not a licensed coding compliance officer. I am a hospitalist physician with years of experience studying this stuff. Read at your own risk. My interpretations here are based on my review of the 1995 and 1997 guidelines and the CMS E/M guide along with the Marshfield Clinic point system for medical decision making. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard in most parts of the country. However, you should check with your own Medicare carrier in your state to verify whether or not they use a different standard than that for which I have presented here on my free educational discussion. I have links to these files available in my hospitalist resource area.
How does the AMA define a 99222/99219/99235? Every physician should have the AMA's CPT 2013 Standard Edition, the most up-to-date authority on CPT® codes.
Initial hospital care (or 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 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.
I rarely, if ever bill a 99222, 99219 or 99235. Why? Because a patient that meets criteria for the mid level admission codes will almost ALWAYS meet criteria for the high level codes 99223, 99220 and 99236. I know this because I know exactly what qualifies for a level 3 admit. Almost all of my patients that would meet level 2 (99222/99129/99235) would meet criteria for a high level 3 admit (99223/99220/99236).
Why? Because, if they qualify for a two, they will qualify for a three with good documentation. I know if my patient doesn't qualify for a level three, it has a 99% chance of being a level one admit (99221/99218/99234) because the requirements to get from a level two to a level three are minimal, but the requirements to get from a level one to a level two are huge.
See how easy this is? Well, the following is minimum you must do in order to qualify for a mid level admit code 99222/99219/99235 and ward off the fraud police. So here it is. The 99222/99219/99235. 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)AND
- 4 elements of the HPI (character, onset, location, duration, associated signs etc. OR status of 3 chronic medical conditions. AND
- 10+ review of systems AND
- All 3 areas documented: Past History (things like medical, medications, allergies) AND Family History AND Social History
ExamAND
- 1995 Guidelines: 8 or more systems documented
- 1997 Guidelines: 9 areas with two bullets each
Decision Making (moderate decision making)
There are three components to deciding the level of decision making complexity. You only need to meet moderate decision making criteria for two out of the three. They are based on a point system. What are they?
- Number of diagnoses and management options: 3 points
- amount and complexity of data to be reviewed: 3 points
- Table of risk: Moderate risk.
So here is a note for a mid level admission 99222/99219/99235. I rarely, if ever, bill the mid level codes. because if they meet criteria for a mid level, they will almost always meet criteria for a high level code, if you document correctly.
C/C: My leg is redHPI28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema. (4 HPI)PMFSHOn no meds. Smoker, Mother with eczema, (3 components)ROSExcept as dictated above, all other systems were reviewed and otherwise negative (10+ROS)Exam120/80 85 102.7 temp, well appearing (3 vitals equals one component)(HENT): NormalEyes: NormalCV: NormalRespiratory: NormalGI: NormalPsychiatric: NormalSkin: Edema, warmth, redness right leg, lines consistent with cellulitis, marked with skin marker.LabsWBC 13K ( one point for documenting lab in complexity of data decision making)Impression
- Cellulitis (new problem) (4 points for number of diagnosis for medical decision making)
PlanAntibiotics. Reviewed with ER physician. (2 points fro documenting discussion of case with another health care provider).
In this case we meet all the requirements for history and physical to bill a mid level admission code (which are the same for a high level admission). The history and physical documentation requirements for the mid level admission codes are the same as the high level (99223/99220/99236) admission codes. The only difference between a high level admission code and a mid level admission code lies in the decision making component.
My documentation supports a mid level medical decision making component. While I got four points for a new diagnosis (considered high level with 4 points), I only got three points in the data section (documenting one lab and discussing with the ER physician is worth 3 total points). My risk table is moderate with prescription management. My overall medical decision making is moderate (highest 2 out of three).
My documentation supports a mid level medical decision making component. While I got four points for a new diagnosis (considered high level with 4 points), I only got three points in the data section (documenting one lab and discussing with the ER physician is worth 3 total points). My risk table is moderate with prescription management. My overall medical decision making is moderate (highest 2 out of three).
For a mid level code you need moderate decision making. For a high level admission you need a high level decision making. And that's where the value of good documentation lies and why I use coding card every day to help me decide between the different decision making levels of care.
That's all you need folks. Several notes. On history and physical examination, you can write "normal" and it constitutes a full exam of that body area. You cannot write "abnormal". You can document a sentence stating "a full review of systems was performed and otherwise negative" without having to write out an essay on your negative review of systems by organ systems. Of course, make sure you do a full review of systems.
You can read more about coding at my free lectures on hospitalist E/M coding with all my previous coding posts. As any great hospitalist knows, what code you bill is entirely dependent on how you document, not how much you document.
LINK TO HOSPITALIST POCKET CODING CARD POST
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CPT® 99222 pin below:
CPT® 99219 pin below:
CPT® 99235 pin below:
