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Training
Outline
This training only covers the basic elements of coding for inpatient evaluation and
management (E/M) services, specifically initial hospital visits, subsequent hospital visits,
discharge services, observations, inpatient consultations, coding based on time, and
prolonged services.
History
Chief Complaint
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical, Family, Social History (PFSH)
Examination
Type
PF
EPF
Initial
Hospital
Visit
Detailed
99219
Observation
Services
99235
99236
99251
99252
Hospital Observation or
Inpatient Care Services
(Including Same Day
Admission and
Discharge)
Inpatient
Consultations
99253
PF
EPF
Medical Decision-Making
Detailed
Comp
X
X
99220
99234
Comp
99223
99218
Exam
X
X
X
X
X
X
X
X
X
99255
X
C = Comprehensive
S = Straightforward
Avg. Time
30
50
X
X
70
NA
NA
X
NA
NA
NA
X
NA
20
40
X
99254
PF = Problem Focused
Time Based
55
X
80
X
L = Low
M = Moderate
110
H = High
Notes:
Codes 99221, 99218, and 99234 can either have straightforward or low medical decision-making.
See slide 21 for information on when and how to code based on time.
4
99231
Type
PF
Subsequent
(Follow-up)
Visit
99232
EPF
Detailed
Exam
Comp
EPF
Detailed
PF = Problem Focused
Comp
99233
PF
Medical Decision-Making
S = Straightforward
25
L = Low
Avg. Time
15
C = Comprehensive
Time Based
M = Moderate
35
H = High
Notes:
Code 99231 can either have straightforward or low medical decision-making.
See slide 31 for information on when and how to code based on time.
Hospital Discharge
Day Management:
Code 99238 or 99239
Inpatient consults:
Code 99251, 99252,
99253, 99254, or 99255
Admission & discharged
on same calendar date:
*Code 99234, 99235 or
99236
Notes: See slides 4-5 and 8-17 for more information on when and how to use these codes.
*For Medicare and CareLink patients, see slides 7 and 16 for information on when
and how to use these codes because these payors have different coding
guidelines.
Prior to admission, patient may have been evaluated at another site of service
(e.g., outpatient hospital, office, emergency department, or nursing facility).
6
Inpatient consults:
Code 99251, 99252, 99253, 99254,
or 99255
Notes: See slides 4-5 and 8-17 for more information on when and how to use these codes.
Prior to admission, patient may have been evaluated at another site of service
(e.g., outpatient hospital, office, emergency department, or nursing facility).
7
99221-99223 +
99238-99239
99221-99223 +
99231-99233 +
99238-99239
Type
Duration of Service
Comments
Notes:
Only one physician can be the admitting physician and only the admitting physician
can use codes 99221-99223.
All other providers should bill the inpatient E/M codes that describe their participation
in the patients care (i.e., subsequent hospital visit or inpatient consultation).
When performed on the same date as the admission, all other outpatient services
provided by the physician in conjunction with that admission are considered part of
the initial hospital care.
If the patient is seen in the office on one day, and admitted on the next day (even if
<24 hours have elapsed) by the same physician, code both the office visit and initial
hospital visit.
8
History
Exam
Comments
99221
Detailed or
comprehensive
Detailed or
comprehensive
Straightforward or low
99222
Comprehensive
Comprehensive
Moderate
99223
Comprehensive
Comprehensive
High
10
11
History
Exam
Comments
99231
Problem focused
Problem focused
Straightforward or low
99232
Expanded problemfocused
Expanded
problem-focused
Moderate
99233
Detailed
Detailed
High
Notes:
The descriptors for these codes include the phrase per day, meaning care for the
day.
If Provider A sees the patient in the morning and Provider B, who is covering for
A, sees the same patient in the evening, the notes for both services are combined
and only one subsequent hospital visit is coded.
If two physicians see the patient and they are in different specialties and are
seeing the patient for different reasons (i.e., different diagnosis), then both may
bill a subsequent hospital visit based on that physicians note and the medical
necessity of the service.
Select a code that reflects all services provided during the date of service.
12
13
14
History
Exam
Comments
99234
Detailed or
comprehensive
Detailed or
comprehensive
Straightforward or low
99235
Comprehensive
Comprehensive
Moderate
99236
Comprehensive
Comprehensive
High
Notes:
When performed on the same date as the admission, all other outpatient services
provided by the physician in conjunction with that admission are considered part of the
initial hospital or observation care.
History
Exam
Comments
99234
Detailed or
comprehensive
Detailed or
comprehensive
Straightforward or low
99235
Comprehensive
Comprehensive
Moderate
99236
Comprehensive
Comprehensive
High
Notes:
In addition to meeting the documentation requirements for history, exam and medical
decision-making, documentation in the medical record should include:
Statement that the stay for observation care or inpatient hospital care involved
eight hours, but less than 24 hours.
Admission and discharge notes written by the billing provider.
Personal documentation by the billing provider indicating presence and face-toface services were provided.
16
99238
99239
Comments
Notes:
Only one hospital discharge service is coded per patient, per hospital stay.
Only the attending physician of record reports the discharge day code.
Discharge service is billed on the date of the actual visit by the provider even if the
patient is discharged on a different calendar date.
Includes, as appropriate:
Final patient exam
Discussion of the hospital stay
Instructions for continuing care
Preparation of discharge records, prescriptions, and referral forms
All other providers performing a final visit should code subsequent hospital care
(9923199233).
17
Subsequent visit by
admitting physician or
visit by another
provider
Admit to
Observation
Status*
Initial observation
care:
Codes 99218,
99219 or 99220
Then admit as
inpatient:
Code 99221-99223
(see slides 8-11)
Notes:
See slides 20-25 for more information on when and how to use these codes.
*For Medicare and CareLink patients, see slides 19 and 21 for information on when
and how to use these codes because these payors have different coding guidelines.
Prior to observation, patient may have been evaluated at another site of service
(e.g., outpatient hospital, office, emergency department, or nursing facility).
18
Admit to
Observation
Status
Notes:
See slides 20-25 for more information on when and how to use these codes.
Prior to observation, patient may have been evaluated at another site of service
(e.g., outpatient hospital, office, emergency department, or nursing facility).
19
99218-99220 +
99217
99218-99220 +
99212-99215 +
99217
99218-99220 +
99212-99215 +
99221-99223
Type
Duration of Service
Comments
Notes:
Billed only by the physician who admitted the patient to observation and was responsible for the
patient during his/her stay.
All other providers should bill the outpatient E/M codes that describe their participation in the
patients care (i.e., office and other outpatient service codes or outpatient consultation codes).
20
99218-99220
99234-99236
99218-99220 +
99217
99218-99220 +
99212-99215 +
99217
99218-99220 +
99212-99215 +
99221-99223
Type
Initial Observation
Care
Observation or Inpatient
Care Services
(Including Same Day
Admission and Discharge)
Duration of
Service
Placed under
observation with
discharge on different
calendar date
or
Under observation <8
hours and discharged
on same calendar
date
>48 hours:
1st calendar day - placed
under observation
+
2nd calendar day discharged
>48 hours:
1st calendar day - placed
under observation
+
2nd calendar day subsequent service
+
3rd calendar day - discharged
>48 hours:
1st calendar day - placed under
observation
+
2nd calendar day - subsequent
service
+
3rd calendar day admitted to
inpatient status
Comments
Notes:
Billed only by the physician who admitted the patient to observation and was responsible for the
patient during his/her stay.
All other providers should bill the outpatient E/M codes that describe their participation in the
patients care (i.e., office and other outpatient service codes or outpatient consultation codes).
21
History
Exam
Comments
99218
Problem focused
Problem focused
Straightforward or low
99219
Expanded problemfocused
Expanded problemfocused
Moderate
99220
Detailed
Detailed
High
Notes:
The descriptors for these codes include the phrase per day, meaning care for the
day.
Select a code that reflects all services provided during the date of the service.
The observation record for the patient must contain dated and timed physicians
admitting orders regarding the care the patient is to receive while in observation, and
progress notes prepared by the physician while the patient was in observation status.
This information is in addition to any record prepared as a result of an emergency
department, outpatient clinic, or nursing facility encounter.
In rare instances when a patient is held in observation status for more than two
calendar dates, the physician must code subsequent services before the discharge
date using outpatient/office visit codes (99212-99215).
22
99217
Comments
Notes:
Billed only by the physician who was responsible for observation care during this stay.
Discharge service is billed on the date of the actual visit by the provider .
Includes:
Final patient exam
Discussion of the hospital stay
Instructions for continuing care
Preparation of discharge records, prescriptions, and referral forms
All other providers performing a final visit should use outpatient/office visit codes (9921299215).
Do not bill the hospital observation discharge management code (99217) if patient was
Admitted to inpatient status, use codes 99221-99223. See slide 8-11 for more
information on when and how when and how to use these codes.
Placed under observation and discharged on the same calendar date, use codes
99234-99236. See slide 15-16 for information when and how to use these codes.
23
The global surgical fee includes payment for hospital observation (codes 99217,
99218, 99219, 99220, 99234, 99235 and 99236) services unless specific
requirements are met.
Observation services may be paid in addition to the global surgical fee only if both of
the following requirements are met:
The hospital observation service meets the criteria needed to justify billing it with
modifiers:
24 - Unrelated E/M service by the same physician during a post-operative
period
25 - Significant, separately identifiable E/M service by the same physician on
the same day of a procedure or other service
57 - Decision for major surgery
The hospital observation service furnished by the surgeon meets all the criteria
for the hospital observation code billed.
See slide 35 for information on when and how to use modifiers with E/M
services.
24
9/18
9/18
Medicare & CareLink
99234-99236
(Provider A)
99218-99220
(Provider A)
99234-99236
(Provider A)
99234-99236
(Provider A)
99218-99220
(Provider A)
99212-99215
(Provider B)
99218-99220
(Provider A)
99212-99215
(Provider B)
99217
(Provider A)
99218-99220
(Provider A)
99212-99215
(Provider A)
99217
(Provider A)
99218-99220
(Provider A)
99212-99215
(Provider A)
99221-99223
(Provider A)
99218-99220
(Provider A)
99218-99220
(Provider A)
9/19
9/20
25
Inpatient Consultations
Codes 99241-99245 are used to report consultations provided to hospital inpatients.
History, exam, and medical decision-making must meet or exceed the same level in order
to assign a specific code (i.e., 3 out of 3 same level or higher).
Code
History
Exam
Comments
99251
Problem focused
Problem focused
Straightforward
99252
Expanded problem-focused
Expanded problem-focused
Straightforward
99253
Detailed
Detailed
Low
99254
Comprehensive
Comprehensive
Moderate
92255
Comprehensive
Comprehensive
High
Notes:
An inpatient consultation may only be billed once per consultant, per admission.
Additional follow-up visits after the initial inpatient consultation are billed using the
subsequent hospital care codes (99231-99233). See slide 12-14 for information on
when and how to use these codes.
A request to take care of the problem is a referral, and should be coded with
subsequent hospital care code 99231-99233. See slide 12-14 for more information
on when and how to use these codes.
26
Inpatient Consultations
These requirements must be met and supported by documentation in the patients
inpatient medical record to code and bill a consultation.
The request for a consultation including the name of the requestor and the need or
reason for the consultation must be documented by the consultant in the inpatients
medical record; and,
Intent is to return the patient to requesting provider for ongoing care of the problem.
27
28
29
30
In an inpatient setting, when more than 50% of the total visit time by the teaching
physician is counseling and/or coordinating the patients care, the time used to code
must be provided at the patients bedside and/or on the patients hospital floor or unit.
When coding based on time, the teaching physician may not:
Add time spent by the resident in the absence of teaching physician to face-toface time spent with the patient by the teaching physician with or without the
resident present .
Count time counseling or coordinating the patients care after leaving the patients
floor or after beginning to care for another patient.
In addition to documenting history and/or physical exam provided, the documentation
should include:
Total visit time and time spent counseling and coordinating care, and,
Description of the medical decision making and counseling discussion and/or
activities coordinated.
Examples of documenting support for coding based on time based:
I spent a total of 30 of 45 minutes on the floor coordinating Davids care and in
discussion with David regarding
30 of 40 minutes of visit at Marys beside discussing .with Mary and her family
was spent discussing
31
Prolonged Services
Codes 99356 and 99357 can be used to report inpatient services involving direct
(face-to-face) care provided beyond the usual E/M service.
Code
E/M Type
30
60
105
50
80
125
99223
70
100
145
99231
15
45
90
25
55
100
99233
35
65
110
99251
20
50
95
99252
40
70
115
55
85
130
99254
80
110
155
99255
110
140
185
99221
99222
99232
99253
Subsequent Visit
Inpatient Consultation
Note: See slides 33-36 for information on when and how to use these codes.
32
Only count the duration of direct face-to-face contact between the physician and the patient
(whether the service was continuous or not) beyond the typical/average time of the E/M visit code
billed for the same date of service. See slide 32 for typical and threshold times and applicable E/M
services.
Must be 30 minutes or more beyond the typical time assigned to the E/M level coded
Example: Average time for 99232 = 25 minutes, so a minimum of 55 minutes would be
required to also bill 99356.
Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes
beyond the final 30 minutes is not reported separately.
Prolonged service of less than 30 minutes total duration on a given date is not separately
reported because the work involved is included in the total work of the E/M codes.
Cannot bill prolonged services:
Based on time spent reviewing charts or discussing a patient with house medical staff
without direct face-to-face contact with the patient, waiting for test results, changes in the
patients condition, end of a therapy, or use of facilities
Without first coding an inpatient E/M service on the same date of service
If the total duration of direct face-to-face time does not equal or exceed the threshold time for
the level of E/M service the provider is billing
When the E/M service is selected based on time, prolonged services may only be reported as the
companion code with the highest code level in that family of codes (i.e., 99223, 99233, or 99255).
See slide 8-14 and 26-30 for information on when and how to bill codes based on time.
33
Documentation is required in the medical record about the duration and content of the
medically necessary E/M service and prolonged services billed.
The start and end times of the visit must be documented in the medical record along
with the date of service.
34
36
Inpatient Modifiers
These are the most frequently used modifiers with inpatient E/M services. However,
there may be others. See TrailBlazers Modifier manual for a complete listing of other
modifiers at http://www.trailblazerhealth.com/Publications/Manuals/.
37
Describe the condition(s) that prompted the visit and support the medical necessity
and level of service coded.
Are coded to the highest degree of specificity (e.g. renal failure vs. chronic kidney
disease, Stage III).
Diagnosis codes are not assigned when a diagnosis is mentioned in the history and is
not addressed, or there is no indication in the current visit note that the diagnosis
affected care.
38
All diagnosis codes must be sequenced (1,2,3, etc.) on the fee ticket.
Sequencing on the fee ticket should follow the same sequence as the diagnosis are
documented in the current visit note.
First-listed code:
Chief complaint (i.e., diagnosis, condition, problem, or other reason for the visit
such as chemotherapy) chiefly responsible for the service provided.
If the reason for the visit was for multiple complaints and each was addressed as
supported by documentation,
The complaint that was most time consuming due to evaluation and/or
management is sequenced first; and,
The remaining complaints are sequenced thereafter based on evaluation
and/or management.
Additional codes:
Newly diagnosed codes that were evaluated and/or treated during the current
service.
Co-morbid conditions that coexist at the time of the service and influence,
require, or affect patient-care or treatment as supported in documentation.
Selecting a diagnosis without sequencing the code is not acceptable.
39
Codes:
1.
2.
3.
1.
2.
3.
493.02
414.01
685.1
99232-25
1.
2.
3.
493.02
414.04
685.1
Procedures:
Incision and drainage of pilondial cyst, simple
10080
3.
685.1
Notes:
When an E/M service and a procedure are coded for the same visit, diagnosis codes
must be linked to both the E/M service and the procedure.
Applying the appropriate modifier to the E/M and procedure code support the medical
necessity of both services. See slide 37 for information on when and how to assign
E/M modifiers.
40
Select, sequence, and link diagnosis codes for each E/M and procedure coded
Select modifiers
Sign the paper fee ticket or authenticate the electronic fee ticket
41
42
43