This is my coding lecture on how to bill the high level hospital in-patient and observation admissions as well as the same day admit/discharge evaluation and management (E/M) codes. These are CPT® codes 99223, 99220 and 99236 respectively. What do these codes represent and why can I group them all together in one free coding explanation? It's because 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. You just need to answer two questions.
- Is the patient observation or in-patient? You write the order for one or the other but you need the help of your hospital utilization review folks to verify they meet criteria for in-patient or observation
- Are you planning on discharging the patient on the same calendar date that you admitted them?
Once you know the answer to these two questions you can figure out which of the three codes you can use to bill the high level admission. I did an in depth explanation over at my post on how to bill mid level CPT® 99232/99219/99235. I'll repeat that explanation here.
CPT® 99223 is the high 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 (low level), CPT® 99222 (mid level) or CPT® 99223 (high level). Which code you pick is dependent on what your documentation supports. Keep reading below to learn the basics of CPT® 99223 coding below.
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 (low level), CPT® 99222 (mid level) or CPT® 99223 (high level). Which code you pick is dependent on what your documentation supports. Keep reading below to learn the basics of CPT® 99223 coding below.
I have several in depth posts on the past that have dealt with CPT® 99223.
- RVU Explained. An explanation of CPT® E&M Code 99223
- How Doctors Get Paid. In the eyes of Medicare you are a 99223.
- How to Bill a CPT® 99223.
Last year, CMS stopped paying for all in-patient consultation codes (CPT® 99251-99255).
This E/M pocket reference card (below) represents my interpretation so 1995 and 1997 CMS guidelines.What does that mean for physicians caring for Medicare patients? It means, if you aren't billing critical care for your initial visit on a hospital in-patient, you must use CPT® 99221, CPT® 99222 or CPT 99223 as your initial billing code even if you didn't admit the patient as the attending physician. All physicians, attending and consultative, should be using CPT® codes 99221-99223 on their initial in-patient evaluation, on Medicare patients.
This E/M pocket reference card (below) represents my interpretation so 1995 and 1997 CMS guidelines.What does that mean for physicians caring for Medicare patients? It means, if you aren't billing critical care for your initial visit on a hospital in-patient, you must use CPT® 99221, CPT® 99222 or CPT 99223 as your initial billing code even if you didn't admit the patient as the attending physician. All physicians, attending and consultative, should be using CPT® codes 99221-99223 on their initial in-patient evaluation, on Medicare patients.
CPT® code 99220 is the high level initial evaluation visit used for patients under observation status in the hospital. The choices here are CPT® 99218( low level), CPT® 99219 (mid level) and CPT® 99220 (high level). 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 complicated. 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. How many lawyers do you think would put up with this in nonsense in their billing department? As you can see, the whole game of evaluation and management (E/M) 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.
The last set of high level codes fall into the inpatient or observation admit and discharge same calendar day category. The three possible codes here are CPT® 99234 (low level), CPT® 99235 (mid level) and CPT® 99236 (high level) admit/discharge same calendar date (using midnight-to-midnight as the cut off). 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. Here is my understanding of these three codes. Find out what calendar date 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 date 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, whether the patient is in-patient or observation status.
No other E/M codes can be billed for the hospital stay. These are the global admit and discharge codes 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, 99235 and 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.
So hopefully you've got the basics down. Is the patient's admit and discharge on the same calendar date using midnight as the cut off marker? If so, use CPT® codes 99234, 99235 or 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, 99222 or 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, 99219 or 99220 as your initial evaluation code of choice. When you eventually discharge the patient, the only code available is CPT® 99217, the only discharge code available for observation patients who discharge on a different date than their observation admission.
Now for why you're here. What are the bare minimum requirements necessary to meet Medicare muster for billing a CPT® 99223, 99220 or 99236 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.
Some carriers in some states utilize the Trailblazer EM tool. There are a few key differences with Trailblazer vs Marshfield in how Medicare carriers are to interpret evaluation and management documentation. Here is asummary of those key differences. Here is the actual link to the Trailblazer E/M Audit reference pdf. If your carrier uses Trailblazer, this discussion may help you, but these additional resources should be reviewed as well for clarity.
How does the AMA define a 99223/99220/99236
?
?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 high 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 70 minutes at the bedside and on the patient's hospital floor or unit.
I almost always bill the high level admission codes 99223, 99220 or 99236. Why? Because almost all of my patients will qualify. 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 CPT® medical coding level 3 admit. Almost all of my patients that would meet level two (99222/99129/99235) would meet criteria for a high level three admit (99223/99220/99236).
Last year I billed a total of ZERO level two admits. 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 the exact bare minimum you must do in order to qualify for a high level admit code 99223/99220/99236 and ward off the fraud police. So here it is. The 99223/99220/99236 documentation requirements. 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)
- 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
AND
Exam
- 1995 Guidelines: 8 or more systems documented
- 1997 Guidelines: 9 areas with two bullets each
It's really complicated and I almost NEVER base my billing on physical exam.
AND
Decision Making (high decision making)There are three components to deciding the level of decision making complexity. You only need to meet high 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: 4 points
- amount and complexity of data to be reviewed: 4 points
- Table of risk: High risk.
Remember, in the decision making component, you need to meet documentation criteria of high risk in just two out of the three areas of diagnosis, data complexity and table of risk. These rules are obnoxious, as you can tell. The decision making explanation is below. Keep reading.
And you thought working through a differential diagnosis was complicated. We almost need a complete residency just in the coding aspects of caring for patients. Take a look at these two picture files below filled with all the specifics rules that determine what level of decision making must be applied for every single E/M code we bill for every single patient encounter. We have to implement this rule set every patient encounter, every time, if we want to get it right and not be accused of fraud. The first picture highlights the point system me must all use. The second is a larger version of the risk table, one of the components of the medical decision making tree. You can click on either to enlarge or print. I highly encourage you print it and study it if you don't want to end up in federal prison for Medicare fraud.
And you thought working through a differential diagnosis was complicated. We almost need a complete residency just in the coding aspects of caring for patients. Take a look at these two picture files below filled with all the specifics rules that determine what level of decision making must be applied for every single E/M code we bill for every single patient encounter. We have to implement this rule set every patient encounter, every time, if we want to get it right and not be accused of fraud. The first picture highlights the point system me must all use. The second is a larger version of the risk table, one of the components of the medical decision making tree. You can click on either to enlarge or print. I highly encourage you print it and study it if you don't want to end up in federal prison for Medicare fraud.
So here is a note for a high level admission 99223/99220/99236. I almost always bill these high level codes because if my patient meets criteria for a mid level, they will almost always meet criteria for a high level code, if you document completely and accurately. If you aren't billing mostly high level codes, you are screwing yourself and the Bell curve for all your colleagues.
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) (8 or more systems)(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 (1of 4 points needed )). Venous doppler report reviewed. No clot. (one point for documenting review of vascular study report. Now with have two of four points in the complexity of data decision making needed to get to high risk))
Impression
- Cellulitis (new problem) (4 points for number of diagnosis for medical decision making)
PlanAntibiotics. Reviewed with ER physician. (2 points for documenting discussion of case with another health care provider which means we now have a total of 4 points in the complexity of data decision making--> High risk criteria met).
In this case we meet all the requirements for history and physical to bill a high level admission code (which are the same for a mid 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. See how easy that is? 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 high level medical decision making component. I got four points for a new diagnosis (considered high level with 4 points), I got four points in the data section (documenting one lab (one point) reviewing one cardiovascular study report (one point) and discussing with the ER physician (two points) is worth a total of four points. That gets me to high risk for decision making. The table of risk doesn't apply. It just doesn't matter. Remember, two out of three medical decision components only have to meet high risk. My decision making is high.
My documentation supports a high level medical decision making component. I got four points for a new diagnosis (considered high level with 4 points), I got four points in the data section (documenting one lab (one point) reviewing one cardiovascular study report (one point) and discussing with the ER physician (two points) is worth a total of four points. That gets me to high risk for decision making. The table of risk doesn't apply. It just doesn't matter. Remember, two out of three medical decision components only have to meet high risk. My decision making is high.
And that's where the value of good documentation lies and why I use my yellow card every day to help me decide between the different decision making levels of care. If I didn't document that I spoke with the ER physician (which I do when they call me), then I would not meet high level criteria. See how good documentation can generate tens of thousands of dollars a year in revenue you may not know you are entitled to by playing by the rules? It's not how much you document. It's what you document.
That's all you need folks. I hope you never bill a mid level admission code. Because if you are, you are screwing yourself out of tens of thousands of dollars a year. If a patient meets criteria for a level two admission, they will almost ALWAYS meet criteria for a level three high level admission. ALWAYS! That's what my experience tells me. In my state, the difference between a mid level admission 99222 and a high level admission 99223 is $125 vs $180. That's $45 per admission. If you aren't billing a high level admission, you are screwing yourself. Just learn some very simple basic coding rules and you can dramatically increase your billing performance and your take home pay.
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 at my free lectures on medical billing and coding. As any great hospitalist knows, what CPT® code you bill is entirely dependent on how you document, not how much you document.
LINK TO E/M POCKET REFERENCE CARD POST
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