CPT® 99999 For Those Really Complicated Patients!

There are many types of patients that we take care of as hospitalists.  All of their inpatient hospital follow up care can be billed out by one of four possible E/M codes.  First is the 99231, a low level hospital follow up code.  Second is the 99232, a mid level hospital follow up code.  Third is the 99233, a high level hospital follow up code.  And finally there is the 99291, a critical care code.  These four codes, in addition to my admission and discharge codes,  account for most of  my inpatient billing.    Make sure to have your own CPT® manual available as a go to guide for questions on CPT® coding.  With the exception of critical care codes, none of these hospital follow up E/M codes are usually billed based on time spent.  You can bill for hospital follow up codes based on time, but you have to meet a different set of rules and regulations.   Anyone who does E/M coding and understands the requirements knows that the variation in complexity between one patient with a 99233 and another patient with a 99233 is huge.   I can give you one example of a high level 99233  hospital follow up SOAP note that takes me five minutes to complete.   
S) ROS unable secondary to delirium
O) 120/80 80 afebrile
INR 2.4
     HTN, stable no changes planned
     COPD, stable, no changes planned
     Delirium, no agitation, stable no changes planned
     Fever, new, check UA, CXR
    A/C mgmnt; INR 2.4 on warfarin
This note may take me 5 minutes to complete, but  it meets every criteria for a high complex hospital follow up visit.  This is a 99233 hospital follow up SOAP note.

Compare that with another patient with a highly complex clinical scenario who's multiple organ failure and dysfunction makes even the smartest of specialists trip over their feet.  I'm taking care of one of those patients right now.  It's a case of multiple organ dysfunction who's complexity just isn't done justice by using E/M code 99233 or even the critical care codes.  That's how complex their care is. There is sick and then there is complicated sick.  There is a huge difference between these two types of patients.  We need another set of codes entirely for the complicated sick population.  No such set of codes exist.
Happy:  You know that lady that you're following with me, we need a new E/M code for her.  The 99233 just doesn't do her justice.  And neither does the 99291.
Doc:  How about a 99999.  That's the highest number you can get
There really are some patients who are in a  league of their own who require a level of care that just can't be appreciated by our current E/M process for capturing complexity of illness.  Based on my experience with the complexity of my patients, I'd say 1/2 my level three hospital follow up and admit codes involve a level of complexity light years above and beyond that which can be captured by the highest current allowable E/M charges.  

It's a travesty to physicians everywhere who care for the most complex patients at a cost and time based expense not appreciated by the current E/M coding limits.  This is why predominant E/M based specialties are failing to recruit adequately.  Patients are living longer, older and sicker than ever before.  And they take more time than ever before to manage well.

I'm here, as a hospitalist, to categorically state that the complexity of my patients and the work required to safely care for their multiple medical issues is not being captured by the current limited codes under E/M guidelines. I think any doctor who does E/M can attest to that.  You can find all my other free coding lectures at my post on  hospitalist billing and coding and all my other practice management links for hospitalists.  

In case you had problems separating truth from reality, CPT® 99999 is not a real code.


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

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Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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