2015 EM Survival Guides Chapter 4: Initial Hospital Care (99221-99223) You should select the appropriate-level initial hospital care code (99221-99223) using the key E/M criteria of history, examination and medical decision-making (MDM). You must meet all three requirements to report a given service level based on the patient s medical necessity and the key criteria as follows: Code History Exam MDM 99221 detailed detailed straightforward/low complexity 99222 comprehensive comprehensive moderate complexity 99223 comprehensive comprehensive high complexity Example: The physician admits a patient to inpatient status for a new problem. She records a comprehensive history and exam, and MDM of moderate complexity. Because you must meet all three requirements to report a given level of initial hospital care E/M, you must report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent at the bedside and on the patient s hospital floor or unit. ) for this service. Exception: You can use time as the controlling factor to report initial hospital care if more than 50 percent of the visit comprises counseling and coordination of care. In the inpatient setting, "time" can mean "floor time" which must be spent on the patients care, but is not necessarily "face-to-face". See the Time chapter for complete instructions on how to code using time as the controlling factor when selecting an E/M code. Report Only One E/M Service per Day Physicians should not report any other E/M services in addition to an inpatient admission on the same day for the same patient, even if the physician sees the patient for completely unrelated problems. The inpatient hospital visit descriptors contain the phrase per day which means that the code and the payment established for the code represent all services provided on that date, according to the Medicare Internet Only Manual (IOM),Publication 100-04, Chapter 12, section 30.6.9 B The big question: So how do you get reimbursed for the total physician work if he provides more than one E/M service on the same day, ending with an inpatient admission? Example: A surgeon sees a patient in the emergency department (ED). After an extensive examination, the surgeon admits the patient to inpatient status. The answer: The physician should select a code that reflects all services provided during the date of the service, the IOM advises. CPT guidelines reiterate this advice: "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (that is, hospital emergency department, observation status in a hospital, physicians office, nursing facility), all [E/M] services that the physician provides in conjunction with that admission are part of the initial hospital care when performed on the same date as the admission." In other words: You should consider the extent of all E/M services the physician provides for the same patient on the same
date of service, and combine them when selecting an appropriate initial inpatient (initial hospital care, per day) E/M code (99221-99223). For instance, in the above example, you may consider the surgeons work in the ED when determining which code to use for the admission. In other words, there is usually overlap between the ED examination and the examination, history and MDM associated with the inpatient admission, and you may therefore consider the work involved in the preadmission ED visit when selecting among the initial care codes. Focus on MDM Medical decision-making is generally the deciding factor when choosing an initial hospital care code because even the lowest-level service requires a "detailed or comprehensive" history and examination (i.e., 99221). When determining the MDM level, the physician must consider three factors: 1. Risk of mortality and morbidity. What are the risks of significant complications, death or co-morbidities associated with the patients presenting problems, diagnostic procedures and/or possible management options? 2. Diagnosis and management options considered. Has the physician established a definitive diagnosis, or are there differential diagnoses? Is the plan of care provisional, depending on further information? Will further assessments, tests, medical studies or consultations* be performed? 3. Records and tests reviewed. How many and how complex were the tests and medical records that the physician had to review and analyze? Did the doctor review the films or tracings himself? (They often do this but rarely document it, although it can substantially increase the MDM level in some situations.) The Presenting Problem Matters The presenting problem in the preadmission service affects MDM, and this can carry over to the service level you chose for the inpatient admission. Heres an example: In the ED, the surgeon sees a patient who struck the steering wheel because he wasn t wearing a seat belt during an automobile collision. The patient initially claims to feel "fine" and protests that he only visited the hospital at the insistence of the police officer who responded to the accident. But during the history and physical, the patient begins to have abdominal pain (789.00), dizziness (780.4) and nausea (787.02) Concerned about the possibility of internal injury, the surgeon admits the patient and, upon exploration, identifies a liver laceration requiring surgical repair (864.05, Liver Injury without mention of open wound into cavity, unspecified laceration). In this case, the nature of the accident and the possibility of serious injury required a high-level history and exam. During the course of the exam, as the patient s symptoms became more apparent, the MDM level also increased because the risk to the patient, as well as the tests the surgeon must review and the diagnosis/management options he must consider, likewise increased. When the surgeon determines that the patient requires admission, the work involved and documented to describe the ED visit carries over to the initial inpatient care codes. The physician doesn t need to record a new history and physical, but he should refer in the inpatient chart to the fact that he evaluated the patient in the ED, linking the ED chart to the inpatient chart. In the above situation, the complexity of MDM, combined with the documented comprehensive history and exam within the two charts, would likely allow you to report a level two (99222) or three (99223) inpatient admission with little or no additional work beyond that included in the ED visit alone. Report Separate E/M if Admission Occurs on Different Date If your physician provides an E/M service in the office on day one and then admits the patient to the hospital on day two, you can legitimately report both services.
The official word: The IOM (Publication 100-04, Chapter 12, Section 30.6.9.1 B) instructs payers that they should, "Pay both visits if a patient is seen in the office on one date and admitted to the hospital on the next date, even if fewer than 24 hours has elapsed between the visit and the admission." Example: The physician sees the patient on Tuesday afternoon for a new problem. The next morning (Wednesday), the patient phones the physician and claims that his symptoms are worsening. The physician sees the patient in the office again that morning, then immediately admits the patient to the hospital. In this case, you can report Office or other outpatient visit (99211-99215, as appropriate) for Tuesday. You can also report the admission/initial hospital care, per day (99221-99223, as appropriate) for Wednesday. Keep in mind, however, that you must include Wednesday morning s office visit (99211-99215, not to be reported separately) in the admission service (99221-99223). Observation example: The physician admits the patient to observation Wednesday at 6 p.m., and admits the patient to the hospital as an inpatient the following day at 6 a.m In this case, you will report one unit of 99218-99220 (Initial observation care, per day Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent at the bedside and on the patient s hospital floor or unit) for the rendered initial observation care on Wednesday and one unit of (99221-99223) for the admission on the subsequent day. You don t get to report observation discharge (99217) with inpatient admission (99221-99223). The physician may not bill the hospital observation discharge management code (99217) or an outpatient/ office established patient visit (99211-99215) for the care provided in observation on the date of admission to inpatient status, according to the IOM. Reporting Services for Two Physicians, One Patient Keep in mind that the rules from 2010 onwards have changed allowing two physicians to report initial inpatient care codes. The admitting physician will report the services with 99221-99223 with the modifier AI (Principal physician of record) while the other physician will report 99221-99223 (Initial hospital care, per day Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent at the bedside and on the patient s hospital floor or unit) or the consultation* codes (99251-99255) depending upon the level of service provided and the payer's policy. Concurrent care limitations are an issue: Generally speaking, you can report a separate service for a non-admitting physician only if that physician is of a different specialty than the admitting physician. The IOM solidifies this by instructing carriers that if two physicians reporting E/M services on the same day "are each responsible for a different aspect of the patients care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses." A cardiologist admits a patient with chest pains (786.50) to the hospital. The patient also experiences muscle twitching (781.0) and slurred speech (784.59), and the cardiologist requests a consultation* from a neurologist prior to the admission In this case, the cardiologist will report the admission (99221-99223), while the neurologist will report the appropriate outpatient consultation* (99241-99245) because the consultation* occurred before the patients admission to inpatient status. Important note: Two physicians of the same specialty may report same-day E/M services for the same patient in some circumstances. See the "Concurrent Care" chapter for more information on this topic. Covering Physicians Can t Report Separate Same-Day Services If your physician is "covering for another physician later on the date of admission, you cannot report a separate E/M service. IOM guidelines dictate, "In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening," payers should not separately reimburse physician B for the second visit.
Same-Day Admission and Discharge Presents a Challenge If the physician admits the patient to inpatient status and discharges the patient on the same date of service, you should not report a separate discharge service. The IOM specifically alerts carriers to "instruct physicians that they may not bill for both an initial hospital care code (99221-99223) and hospital discharge management code (99238-99239) on the same date." Proper coding in these situations is sticky, in part because CMS (Medicare) instructions do not match CPT (AMA) instructions. And some local carriers further specify guidelines that go beyond national Medicare policy. According to CPT : If the physician admits and discharges the patient on the same day, you should report only the observation/inpatient hospital care codes (99234-99236, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent at the bedside and on the patient s hospital floor or unit) rather than initial inpatient services (99221-99223) and a hospital discharge (99238-99239). Example: The physician admits a patient to inpatient status at 9 a.m. and discharges her later that day at 8 p.m. Because the admission and discharge occur on the same date, you should report 99234-99236 only, as appropriate to the documented service level, per CPT instructions. CPT Rules for Admission and Discharge Services Admit and discharge on: Same date Different dates Report Admission 99234-99236 99221-99223 Report Discharge Not separate 99238-99239 According to national Medicare guidelines as outlined in the IOM (Chapter 12, section 30.6.9.1C), carriers should "pay only the initial hospital care code [that is, 99221-99223] when a patient is admitted as an inpatient and discharged on the same day."the IOM further instructs payers, "Do not pay the hospital discharge management code on the date of admission." Example: Therefore, according to IOM instructions, if the physician admits a patient to inpatient status at 9 a.m. and discharges her later that day at 8 p.m., you would report only 99221-99223 (not 99234-99236), as appropriate to the service level. You would not report a separate discharge code. IOM (National Medicare) Rules for Admission and Discharge Services Admit and discharge on: Same date Different dates Report Admission 99221-99223 99221-99223 Report Discharge Not separate 99238-99239 Local carriers add another wrinkle: Many local Medicare carriers specify still different guidelines for same-day admission and discharge These payers suggest that 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date Counseling and/or coordination of care with other physicians, other qualified healthcare professionals Typically are spent at the bedside and on the patient s hospital floor or unit) may be appropriate for same-day admit and discharge, but only if the inpatient stays lasts a minimum of eight hours. For inpatient stays of fewer than eight hours, you should report 99221-99223 (Initial hospital care, per day ) without a separate discharge code. One typical payer policy states, "For a physician to appropriately report CPT codes 99234 through 99236, the patient must be an inpatient or an observation care patient for a minimum of 8 hours on the same calendar date. For an inpatient admission with discharge less than 8 hours later on the same calendar date, CPT codes 99221 through 99223 must be used for the admission service and the hospital discharge day management service (99238-99239) must not be billed." Example: Under these guidelines, you would report 99234-99236 for a patient admitted at 9 a.m. and discharged at 8 p.m. because the visit lasted more than eight hours. If, however, the physician admitted the patient at 9 a.m. and discharged
her at 4 p.m. (seven hours later), you would report 99221-99223 only, with no discharge code. Various Local Medicare Carrier Rules for Admission and Discharge Services Admit and discharge on: Same date (< 8 hours) Same Date Different (>8 hours) dates Report Admission 99221-99223 99234-99236 99221-99223 Report Discharge Not separate Not separate 99238-99239 Get it right Ask your payer for guidance: Because of the contradictory information on appropriate coding for same-day inpatient admissions and discharges, you should ask your payer for guidance (in writing) on how to handle these services Same-day Procedure, Admission Calls for a Modifier You may bill hospital admission (99221-99223) for the same date of service as a procedure under the appropriate conditions, and if you append modifier 57 (Decision for surgery) to the E/M service code. The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself, and includes one pre-procedure E/M service for patient evaluation. For this reason, payers will normally bundle any E/M service provided on the same day as a major procedure to the procedure itself. If the E/M service precedes and leads to or results in the initial decision to perform surgery, you may report the service separately, according to CPT rules, by appending modifier 57. Important: You may not bill for the initial E/M service, however, if the surgery was scheduled prior to the admit. Example: The surgeon sees a patient with extreme pain in the lower abdomen (789.09). The physician quickly determines that the patient s appendix has burst and schedules immediate surgery. In this case, you can bill both the E/M service and the surgery because the E/M service resulted in the decision to perform the surgery (in other words, the physician had not previously planned the surgery at the time of the evaluation) - Published on 2018-01-01