Basic Inpatient E/M Coding Training

1. Basic Inpatient E/M Coding Training Office of Regulatory Affairs & Compliance

2. 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. • Components of E/M Services • Inpatient E/M Inpatient Services • Initial Hospital Visits • Subsequent Hospital Visits • Hospital Discharge Services • Hospital Observation Services • Inpatient Consultations • When to Use Time Based Coding • Prolonged Services • Most Frequently Used Modifiers • Selecting, Sequencing and Linking Diagnosis Codes • Completing Fee Tickets • Teaching Physician Attestations for E/M Services

3. Components of E/M Inpatient Services Inpatient E/M services have the same basic components as outpatient E/M. Below are the basic components: • History • Chief Complaint • History of Present Illness (HPI) • Review of Systems (ROS) • Past Medical, Family, Social History (PFSH) • Examination • Medical Decision-Making (MDM) • Number of diagnoses or management options • Amount and/or complexity of data reviewed or ordered • Risk of complications and/or morbidity or mortality

4. Overview of Inpatient E/M LevelingThe codes listed in the left hand column require 3 of 3 components be met or exceeded. • 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.

5. Overview of Inpatient E/M LevelingThe codes listed in the left hand column require 2 of 3 components be met or exceeded; 1 of the 2 must be medical decision-making. 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.

6. Overview of Inpatient Visits Subsequent follow-up or encounter by provider other than admitting physician: Code 99231, 99232 or 99233 Initial hospital care: *Code 99221, 99222 or 99223 Hospital Discharge Day Management: Code 99238 or 99239 Admit to hospital as inpatient 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).

7. Overview of Inpatient Visits - Medicare & CareLink Admission < 8 hours: Code 99221, 99222 or 99223 Admit to hospital as inpatient Admission > 8 hours but < 24 hours & discharged on same calendar date as admission: Code 99234, 99235 or 99236 Admission > 24 hours: Code 99221, 99222 or 99223 Subsequent visit by admitting physician or visit by provider other than admitting physician: Code 99231, 99232 or 99233 Hospital Discharge Day Management: Code 99238 or 99239 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).

8. Initial Hospital VisitsCodes 99221-99223 are used by the admitting physician to report initial services to hospital inpatients. These codes are often referred to as the “Admit” codes. 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 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 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.

9. Initial Hospital VisitsHistory, 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).

10. Initial Hospital Visit - Clinical Example The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code. The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem. Initial hospital visit for a 50 year old patient with lower quadrant abdominal pain and increased temperature, but without septic picture. Based on this example, what code should be assigned? For the answer, see the next slide.

11. Initial Hospital Visit - Clinical Example Based on the example in the preceding slide, the service provided and documented should support initial hospital visit code 99222.

12. Subsequent Hospital VisitsCodes 99231-99233 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). 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 physician’s note and the medical necessity of the service. • Select a code that reflects all services provided during the date of service.

13. Subsequent Hospital Visits - Clinical Example The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code. The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem. Subsequent hospital visit for 55 year old male with severe chronic obstructive pulmonary disease and bronchospasm; initially admitted for acuter respiratory distress requiring ventilator support in the ICU. The patient was stabilized, extubated and transferred to the floor, but has not developed acute fever, dyspnea, left lower lobe rhonchi and laboratory evidence of carbon dioxide retention and hypoxemia. Based on this example, what code should be assigned. For the answer, see the next slide.

14. Subsequent Hospital Visits - Clinical Example Based on the example in the preceding slide, the service provided and documented should support initial hospital visit code 99233.

15. Observation or Inpatient Hospital Care(Including Admission and Discharge Services)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. 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. • When a patient is admitted to observation or inpatient care and discharged on a different date, see slides 4, 6-11 and 17 for information on when and how to use the initial hospital care codes 99221-99223 and discharge management codes 99238-99239, or slides 18-25 on when and how to use hospital observation codes 99218-99220 and observation care discharge code 99217.

16. Observation or Inpatient Hospital Care – Medicare and CareLinkCodes 99234-99236 are used by a provider to report: Admitting and discharging a patient on the same calendar day for >8 hours but <24 hours, or Placing a patient under observation and discharging the patient on the same calendar date for >8 hours but <24 hours 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-to-face services were provided.

17. Hospital Discharge Day Management Codes 99238-99239 are used to report the total duration of time spent by the provider for final hospital discharge services. 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 • Total time of the visit must be documented to support code assigned. • All other providers performing a final visit should code subsequent hospital care (99231–99233).

18. Hospital Observation Services Subsequent visit by admitting physician or visit by another provider Code 99212, 99213, 99214, or 99215 Then use discharge code 99217 Initial observation care: Codes 99218, 99219 or 99220 Admit to Observation Status* Outpatient consultation: Code 99241, 99242, 99243, 99244, or 99245 Then admit as inpatient: Code 99221-99223 (see slides 8-11) Admission & discharged on same calendar date: *Code 99234, 99235 or 99236 • 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).

19. Hospital Observation Services – Medicare and CareLink In Observation < 8 hours and discharged same calendar date: Code 99218, 99219 or 99220 In Observation > 8 hours but < 24 hours and discharged same calendar date: Code 99234, 99235 or 99236 (see slide 15) Admit to Observation Status When discharged, use observation care discharge day management: Code 99217 In Observation > 24 hours: Code 99218, 99219 or 99220 In Observation > 48 hours: Code 99218, 99219 or 99220 then 99212-99215 If admitted, use initial hospital visit: Code 99221, 99222 or 99223 (see slides 8-11) 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).

20. Hospital Observation ServicesThese codes are used to report a patient placed under observation and include initiation of observation status, supervision of care, and periodic assessments. 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 patient’s care (i.e., office and other outpatient service codes or outpatient consultation codes).

21. Hospital Observation ServicesHistory, 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). 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 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. • 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. Observation Care Discharge Services Code 99217 is used to report discharge services of a patient in observation status. 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 (99212-99215). • 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. Hospital Observation During A Global Surgical Period • 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. How to Use Observation Codes - Examples

25. Inpatient ConsultationsCodes 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). 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 patient’s inpatient medical record to code and bill a consultation. • The service is provided by a physician or qualified non-physician provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by provider (excludes residents, fellows, and interns) due to the consultant’s expertise in a specific medical area beyond the requesting provider’s knowledge; and, • 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 inpatient’s medical record; and, • After the consultation is provided, a written report of the consultant’s findings, opinions, and recommendations is documented in the inpatient record for the requesting provider to use in the management of and/or decision making for the patient; and, • Intent is to return the patient to requesting provider for ongoing care of the problem. • During the service, the consultant may: • Perform or order diagnostic tests, or • Initiate a treatment plan, including performing emergent procedures.

27. Examples of Disposition Boxes for Consultation Services Templates Here are examples that you may include in your documentation templates to support your intent to return the patient to the requestor. ❑ Return to requesting provider with recommendations and treatment options. ❑ Return to requesting provider’s care with final recommendations after completion of additional diagnostic testing. ❑ Return to requesting provider’s care with final recommendations after evaluation of trial of therapeutic regimen. ❑ Will follow for X problems in parallel with requesting provider if provider agrees.

28. Inpatient Consultations - Clinical Example The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code. The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem. Initial inpatient consultation for a 72 year old male with emergency admission for possible bowel obstruction. Based on this example, what code should be assigned. For the answer, see the next slide.

29. Inpatient Consultations - Clinical Example Based on the example in the preceding slide, the service provided and documented should support initial hospital visit code 99254.

30. When to Use Time Based Coding • In an inpatient setting, when more than 50% of the total visit time by the teaching physician is counseling and/or coordinating the patient’s care, the time used to code must be provided at the patient’s bedside and/or on the patient’s 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-to-face time spent with the patient by the teaching physician with or without the resident present . • Count time counseling or coordinating the patient’s care after leaving the patient’s 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 David’s care and in discussion with David regarding…” • “30 of 40 minutes of visit at Mary’s beside discussing ….with Mary and her family was spent discussing…”

31. Prolonged ServicesCodes 99356 and 99357 can be used to report inpatient services involving direct (face-to-face) care provided beyond the usual E/M service. Note: See slides 33-36 for information on when and how to use these codes.

32. When to Use Prolonged Service Codes • 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 patient’s 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 for Prolonged Services • 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. • The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the provider personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.

34. Prolonged Services - Clinical Example The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code. The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem. A 34 year old primigravida presents to hospital in early labor. Admission history and physical reveals severe preeclampsia. Physician supervised management for preeclampsia, IV magnesium initiation and maintenance, labor augmentation with pitocin, and close maternal-fetal monitoring. Physician face-to-face involvement includes 40 minutes of continuous bedside care until the patient is stable, then is intermittent over several hours until the delivery. Based on this example, what code should be assigned. For the answer, see the next slide.

35. Prolonged Services - Clinical Example Based on the example in the preceding slide, the service provided and documented should support initial hospital visit code 99356.

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/. • 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. • 57 - Decision for major surgery. • GC - Service performed in part by a resident under direction of a teaching physician.

37. Tips on Selecting Diagnosis Codes This information will assist in the selection of diagnosis codes used to bill an E/M service. Diagnosis codes: • Describe the condition(s) that prompted the visit and support the medical necessity and level of service coded. • Must be supported by documentation in the current note. • Are coded to the highest degree of specificity (e.g. renal failure vs. chronic kidney disease, Stage III). • May be taken from final assessment or chief complaint. • Can be based on signs/symptoms if unable to make definitive diagnosis during the visit. • Cannot be coded for conditions documented as “rule out… probable... possible…questionable…”. • Include secondary conditions affecting treatment during the current visit. • 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. Tips on Sequencing Diagnosis Codes • 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. Example of Linking Diagnosis Codesto E/M Services and Procedures The patient was admitted 2 days ago with acute exacerbation of asthma and native vessel CAD. Today, a painful pilondial cyst was also evaluated and the cyst was incised and drained. Notes supporting the subsequent hospital visit and I&D were fully documented in the patient’s medical record. 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. Completing A Fee Ticket • Select E/M level • Select additional service or procedure codes as applicable • 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. Documenting a Teaching Physician Attestation for E/M Services The teaching physician does not have to re-perform and re-document the entire E/M service to bill. However, the teaching physician, at minimum, must personally document an attestation to supplement the resident’s documentation. • The attestation includes a statement that the teaching physician: • Personally performed the service, or was physically present during the key or critical portions of the service when performed by a resident; • Participated in the management of the patient; and, • Reviewed the resident’s note. The name of the resident should be included in the attestation. • When properly attested, the resident’s documentation and the faculty’s documentation can be used by the teaching physician to determine the level of E/M service billed and support medical necessity.

42. Examples of Teaching Physician Attestations for E/M Services • Examples of acceptable attestations: • “I saw and evaluated the patient. I agree with the findings and plan of care documented in Dr. Resident’s note.” • “I saw the patient with Dr. Resident and agree with his findings and plan.” • “I saw the patient and discussed the patient with Dr. Resident and agree with the note except that the findings are more consistent with…. Will begin ….” • Examples of unacceptable attestations: • “Discussed with resident and agree.” • “Patient seen and evaluated.” • “Agree with the above.” • It is also unacceptable for a resident to attest to a teaching physician’s presence and participation in an E/M service. • For example, “I saw and evaluated the patient with Dr. Faculty who agrees with my findings and plan of care.”

43. Questions If you have any questions, please contact: Your UT Medicine Coder Educator or Office of Regulatory Affairs & Compliance at 567-2014