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 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® 99221-99223. Which code you pick is dependent on what your documentation supports. All physicians, attending and consultative, should be using CPT® codes 99221-99223 or critical care codes on their initial in-patient evaluation for on Medicare patients as consult codes have been eliminated.
CPT® code 99220 is the high level initial evaluation visit used for patients under observation status in the hospital. The choices here are CPT® 99218-99220. Which code you pick is dependent on what your documentation supports.. 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.
CPT® code 99220 is the high level initial evaluation visit used for patients under observation status in the hospital. The choices here are CPT® 99218-99220. Which code you pick is dependent on what your documentation supports.. 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. As you can see, the whole E/M process is complicated and scary as physicians risk being thrown in jail and fined tens of thousands of dollars every time they bill 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 -99236 admit/discharge same calendar date. 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.
CPT® 99234-99236 applies to patients whether they are observation or in-patient status. 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 99234-99236 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, 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 minimum requirements necessary 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. I offer links to these resources in my hospitalist practice management area. 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.
How does the AMA define a 99223/99220/99236? I recommend you obtain a copy of the AMAs most recent CPT 2013 Standard Editionas the definitive authorit on CPT® coding.
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 (55 minutes for 99236).
See how easy this is? Well, the following is the 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. 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.
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 E/M reference card detailed below 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 coding for the hospitalist. As any great hospitalist knows, what code you bill is entirely dependent on how you document, not how much you document.
LINK TO E/M POCKET REFERENCE POST
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CPT® 99223 pin:
