99223 vs 99233: Coding Hospital Inpatient Initial Care Encounters.

When should I code a 99223 vs 99233 for the hospital inpatient initial care encounter?   I was recently asked by a busy hospitalist to comment on this scenario as it relates to their consultative role on post operative surgical patients on the orthopedic service.  Here is their question in detail:

We see a lot of orthopedic consults on our service. Sometimes 6-8 new consults per day piled on to our starting census. They often have no acute medical condition that we are commenting on. However, they usually have 4 medical conditions and are on opiate PCA as per orthopedic admission orders. In these situations would I do better to do a 99233 or go to a 99223 due to the 4 diagnoses and the IV PCA? I am already planning on going to a 99233 or less on the less complex ones... I want to maximize return but minimize the documentation work load so I can get thru them and see the other 16+ ( including ICU).

For reference, I am a practicing clinical hospitalist with 15 years of experience. I have studied billing and coding for years and have an excellent foundation for applying coding decisions to real life scenarios.  Before I begin my discussion I think it's important to define what these numbers mean.  CPT® stands for Current Procedural Terminology.  If you don't understand CPT®, I have provided insight here.  CPT® codes are used by medical professionals to bill insurance for their service.  Evaluation and Management (E/M) codes are a subset of CPT® codes.  Evaluation and Management codes include office visits, hospital visits and nursing home visits. There are many CPT® codes that are appropriate for hospital based billing.  I have detailed many of them in my post on CPT® admission codes.

The hospital inpatient initial care codes are CPT® 99221-99223.  The hospital inpatient subsequent care codes are CPT® 99231-99233.  This hospitalist is asking me if they should bill the highest level initial care code or the highest level subsequent care code for their initial encounter as a consultant.  I have previously reviewed both CPT® 99223 and CPT® 99233.  Understanding the key components for both levels of service are critical to understanding this lecture.  I recommend all readers obtain their own copy of the American Medical Association's CPT® manual for their own reference.  You can find one by clicking on the CPT® graphic to the right.

Answering this question requires further discussion on some basic coding decisions.  Is coding a hospital inpatient initial care encounter (99221-99223)  appropriate?  Is coding a hospital inpatient subsequent care code (99231-99233) appropriate?  Are there alternative codes that are more appropriate?  Is choosing the highest level of service appropriate in this described scenario?


The answer is yes.  It is appropriate to choose a hospital inpatient initial care code for the first encounter as a consultant (or as the attending).  While some insurance companies may still recognize consult codes,  Medicare stopped doing so in 2010.   They don't recognize inpatient consult codes (99251-99255) and they don't recognize outpatient consult codes (99241-99245).  For hospital inpatients, Medicare guidance says to choose a CPT® code from the  hospital inpatient initial care code group 99221-99223.  Here is the CMS guidance (on page 16 of the document):
Effective January 1, 2010, the consultation codes are no longer recognized for Medicare part B payment. Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223)...
Most hospitals require a preoperative history and physical (H&P) to be on the chart before a patient goes to surgery.  These H&Ps may be done the the operating surgeon or the patient's primary care physician several days to several weeks before surgery.  This has no relevance for the hospitalist asked to see the patient for medical management after surgery.   All physicians are directed to utilize the hospital inpatient initial care codes for their first encounter whether or not the primary care physician did a complete history and physical before surgery.


The answer is yes.  It is also appropriate to code a hospital inpatient subsequent care code as the initial encounter as a consultant (or as the attending) instead.  I know I just got done explaining why hospital inpatient initial care codes are the correct choice for the first patient encounter.  However, hospital inpatient subsequent care codes can also be used for the first encounter by a physician or other non-physician practitioner (NPP).   The Centers for Medicare & Medicaid Services (CMS)  says they can.  Page 3 of MLN Matters document MM6740  specifically says:
In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.
That means if the physician or other NPP only provided documentation to support a hospital inpatient subsequent care visit, they should bill for a subsequent care visit, even if it was their initial inpatient hospital encounter.  In fact, one Medicare carrier specifically states that in this Q&A document (link no longer active):
If the documentation for the initial visit does not support one of the initial inpatient procedure codes, CMS has instructed contractors to not find fault with the physician billing a subsequent care procedure instead.


Now that I've established physicians and other NPPs can code from either the initial care or subsequent care code groups, the question specifically referred to coding the highest level of service in both code groups, the level three visit.  Some readers may find themselves asking whether billing the highest level of service (99223 for initial care or 99233 for subsequent care) is appropriate, ethical,  fraudulent or irresponsible given the lack of  acute medical conditions in the presented scenario.  These readers do not understand the nature and complexity of the E/M rules.  These readers fail to appreciate that any postoperative orthopedic patient IS an acute patient with profound implications on the stability of their multiple chronic medical conditions and a thorough history and physical will always be medically reasonable and necessary.

The threshold for payment by Medicare is "reasonable and necessary" services.  Managing patients with multiple chronic stable medical conditions such as diabetes (DM), hypertension (HTN), coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD) can be complex in the postoperative state.  Just because all of their medical conditions were stable before surgery does not mean they will be stable after surgery.  Part of the postoperative evaluation is to verify stability or to search for clues on history or physical that may indicate an acute or subacute risk of decompensation.  Just because the patient's medical conditions are stable postoperatively does not mean medically reasonable and necessary care can't rise to the highest level of service code encounter.   Remember, choosing the correct code is not a magic trick.  The rules are highly complex, but well defined.  I have created my own E/M pocket cards (see below) to help me stay compliant with correct coding decisions on every patient encounter.

Is it medically reasonable and necessary to do a complete review of systems (ROS) or a complete physical exam on a stable post operative orthopedic patient with multiple stable chronic medical conditions.  The answer is yes.  These are systemic diseases with systemic complications being managed with medications that have systemic side effects.  Just because the patient had stable disease before surgery does not mean their chronic medical conditions will remain stable after surgery.  Doing a complete ROS or complete physical exam will always be medically reasonable and necessary for patients with multiple chronic medical conditions.

If medically reasonable and necessary care documentation supports the highest level of service 99233 vs 99223, then the highest level of service should be billed.  The E/M medical decision making rules contain elements that can achieve high complexity even with no acute change in medical condition. For example, if you are managing intravenous PCA opiates and their potential for systemic side effects or complications, you should consider this high risk on the E/M risk table and bill your E/M code appropriately.  If you are managing Coumadin in the postoperative orthopedic population, I have previously explained why I believe this is high risk drug therapy on the E/M table of risk table and the correct code should be based on that assumption.

Nowhere does guidance tell us that having only stable chronic medical conditions excludes the physician or other NPP from billing the highest level service codes.  In fact, it's just the opposite.   E/M rules specifically tell us how to define medical decision making (MDM) complexity for patients with multiple chronic medical conditions. Having four stable chronic medical conditions provides four points in the diagnosis section of MDM.  Managing a PCA or Coumadin is considered high risk on the risk table.  That means these post operative ortho consults can be a level 3 visit if the medically reasonable and necessary history and/or physical exam documentation supports it as well.    What if the patient is not on a PCA or they are not on Coumadin?  Always consider the work you do in the data component of MDM as well.  Did you personally document that you reviewed the preoperative ECG tracing?  Did you personally look up old records to compare the ECG or to find evidence of a previous cardiac stress test result?  Did you review the patient's CXR report or their lab?   All of this work adds to the complexity of care and can rise to the level of the highest service code group, if you just remember to document the work you are providing.


Medicare uses relative value units (RVUs) to determine value for all services.  I have previously written posts explaining RVUs and the RVU to dollar conversion.  What is the RVU difference between the highest level hospital inpatient initial care code (99223) and the highest level hospital inpatient subsequent care code (99233) in 2017?
  • 99223 (initial care) -  3.86 work RVU and 5.73 total RVU
  • 99233 (subsequent care) -  2.0 work RVU and 2.95 total RVU
The RVU to dollar conversion rate for 2017 is $35.8887.  That means billing a subsequent care code instead of an initial care code will be worth 1.86 less work RVUs (around $67 dollars less) and 2.78 less total RVUs (around $100 less) in my home state.

Since doing a complete history and complete physical exam in patients with multiple medical problems will always be medically reasonable and necessary, the question the provider then must ask is whether they wish to provide such an intensity of service.  Some readers may ask if the provider believes they don't need to provide a complete history and physical, then doing so would not be medically reasonable and necessary.   This is just not true.  Failure to provide thoroughness does not make it unreasonable and unnecessary.  At the end of the day, it's not up to the patient to determine the level of service a physician provides.  It's up to the physician and their medical judgement about what they feel is the appropriate level of care and to make sure their documentation supports the work they do.


The hospitalist asked the question whether they would do better billing a 99223 or a 99233 for their 6-8 orthopedic consults per day.  Economically, the answer is obvious.  Billing the hospital inpatient initial care codes provides nearly $100 per encounter more of additional revenue, but that benefit comes with a time cost, the value of which can only be determined by the hospitalist making the coding decisions.   At eight consults a day, that's $800 per day of additional revenue by coding a 99223 instead of a 99233.  This assumes a 100% Medicare service and all encounters support  the highest level of service within the code group (99223 or 99233).  Assuming the same high complexity MDM for both code groups, the decision to bill a 99223 vs 99233 comes down to how much additional time the physician wants to spend performing a complete review of systems and a complete physical exam and a past medical, family and social history.    All of these elements are required to correctly code a 99223 encounter but not a 99233.    All are medically reasonable and necessary for patients with multiple relevant chronic medical conditions in the postoperative state.  I would never find fault with a physician for providing this high intensity of service.  The question, eluded by the reader, comes down to time management triage decisions.

Physician time is not unlimited.   Not all doctors have time to provide the highest intensity of service for every encounter and I would never fault them for failing to do so.  Being understaffed is a common theme for many hospitalists and they must triage their time to the sickest patients.   That means the intensity of service provided to some patients may decline.  This will presumably be reflected in a lower coding curve.  Whether that is a good thing or a bad thing is a matter of debate.  Physicians should bill for the medically reasonable and necessary service they provide.   The correct code is the code that is supported by their documentation of medically reasonable and necessary care, without regard to the coding distribution curve of their colleagues.   If they choose to provide a lower or higher intensity of service, that's their decision to make, as long as the care they provide  is also reasonable and necessary.


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

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