Inpatient evaluation and management (E/M) services

Inpatient evaluation and management (E/M) services

                Initial hospital visits,

               Subsequent hospital visits,

               Discharge services,

               Observations,

               Inpatient consultations,

Components of E/M Inpatient Services

Inpatient E/M services have the same basic components as outpatient E/M. 

   

Below are the basic components:

1.      History

a.       Chief Complaint

b.      History of Present Illness (HPI)

c.       Review of Systems (ROS)

d.      Past Medical, Family, Social History (PFSH)

2.      Physical Examination

3.      Medical Decision-Making (MDM)

a.        Number of diagnoses or management options

b.       Amount and/or complexity of data reviewed or ordered

c.        Risk of complications and/or morbidity or mortality

Initial Hospital Visits

CPT Codes 99221, 99222, & 99223 are used by the admitting physician to report initial services to hospital inpatients. These codes would be referred as the “Admit” codes.

¡  Only one physician can be the admitting physician and only the admitting physician can use codes 99221-99223.

CPT 99221 – Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:

A detailed or comprehensive history;

A detailed or comprehensive examination; and 

Medical decision making that is straightforward or of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 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 health care professionals, 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. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 99223 - 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 high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.

¡  All other providers should bill the inpatient E/M codes that describe their participation in the patient’s 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 as part of the initial hospital care. Hence no need to code office visit for the same physician.

¡  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.

Subsequent Hospital Visits

Codes 99231, 99232, 99233 can be used by any provider to report subsequent inpatient services.

Two out of 3 components of history, exam, and medical decision-making must meet or exceed the same level to assign a code (1 of the 2 has to be medical decision-making).

CPT 99231 - Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

A problem focused interval history;

A problem focused examination;

Medical decision making that is straightforward or of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 99232 - Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

An expanded problem focused interval history;

An expanded problem focused examination;

Medical decision making of moderate complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 99233 - Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

A detailed interval history;

A detailed examination;

Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

n  The descriptors for these codes include the phrase “per day,” meaning care for the day.

A.    One Physician sees the patient in the morning and second physician sees the same patient in the evening (Both providers belong to same specialties) - only one subsequent hospital visit is allowed.

B.     If two physicians see the patient and they are in different specialties and are seeing the patient for different reasons, then both may bill a subsequent hospital visit.

Observation or Inpatient Hospital Care (Including Admission and Discharge Services)

CPT Codes 99234-99236 are used by a provider to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service. 

CPT 99234 - Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 99235 – Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, 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 health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 99236 - Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components:

A comprehensive history;

A comprehensive examination; and

Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit.

Report this code if the provider admits the patient to observation or to an inpatient status and discharges him on the same day.

Inpatient status includes a minimum of 8 hours, but less than 24 hours.  When selecting an E/M service level for observation or inpatient hospital care, there are three key components that must be met in order to report the code appropriately.  These components are in addition to the medical necessity for performing the procedures.

n  When a patient is admitted to observation or inpatient care and discharged on a different date use CPT codes 99238-99239

Hospital Discharge Day Management

CPT Codes 99238-99239 are used to report the total duration of time spent by the provider for final hospital discharge services.

CPT 99238 – Hospital discharge day management; 30 minutes or less

Report this code when the provider offers services to the patient on the day of discharge from the hospital. Physician spends less than 30 minutes directly or indirectly with the patient. 

CPT 99239 - Hospital discharge day management, more than 30 minutes

Notes:

n  Only one hospital discharge service is coded per patient, per hospital stay.

n  Only the attending physician of record reports the discharge day code.

n  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.

n  Includes, as appropriate:

Final patient exam

Discussion of the hospital stay

Instructions for continuing care

Preparation of discharge records, prescriptions, and referral forms

n  Total time of the visit must be documented to support code assigned.

n  All other providers performing a final visit should code subsequent hospital care (99231–99233).

Hospital Observation Services

These codes are used to report a patient placed under observation and include initiation of observation status, supervision of care, and periodic assessments.

n  Billed only by the physician who admitted the patient to observation and was responsible for the patient during his/her stay.

n  All other providers should bill the outpatient E/M codes that describe their participation in the patient’s care (i.e., office and other outpatient service codes or outpatient consultation codes).

CPT 99218 – Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components:

A detailed or comprehensive history;

A detailed or comprehensive examination; and

Medical decision making that is straightforward or of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 to "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 99219 – Initial observation 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 health care professionals, 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 to "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.

CPT 99220 - Initial observation 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 high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 to "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.

Hospital Observation Services - History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (3 out of 3 same level or higher).

n  The descriptors for these codes include the phrase “per day”, meaning care for the day.

n  Select a code that reflects all services provided during the date of the service.

n  The observation record for the patient must contain dated and timed physician’s 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.

n  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).

Observation Care Discharge Services

Code 99217 is used to report discharge services of a patient in observation status.

n  Billed only by the physician who was responsible for observation care during this stay.

n  Discharge service is billed on the date of the actual visit by the provider.

CPT 99217 - Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])

n  Includes:

 Final patient exam

                   Discussion of the hospital stay

 Instructions for continuing care

 Preparation of discharge records, prescriptions, and referral forms

n  All other providers performing a final visit should use outpatient/office visit codes (99212-99215).

n  Do not bill the hospital observation discharge management code 99217 if patient was

Admitted to inpatient status, then use CPT codes 99221-99223. 

Placed under observation and discharged on the same date, use codes 99234-99236. 

Hospital Observation during A Global Surgical Period

n  The global surgical fee includes payment for hospital observation (codes 99217, 99218, 99219, 99220, 99234, 99235 and 99236) services unless specific requirements are met.

n  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