EM Coding Alert

Remember that inpatient stays longer than one day may require different codes.

If your provider is caring for patients who require inpatient hospitalization, you need to be able to navigate the evaluation and management (E/M) section of your CPT^® manual with confidence.

Knowing what length of stay requires which code is a fact-based science but may feel more like interpretative art at first. See what experts have to say about hospital care coding.

Context: There are four different groups of hospital care codes; some you’ll use on their own, others you’ll need to use in combination depending on encounter specifics. Also, remember to keep up your count of components (history, examination, medical decision making [MDM]) — unlike the new rules for office/outpatient evaluation and management (E/M) services.

Rely on These Hospital Care Code Sets

There are four categories of hospital care codes, confirms Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, New Jersey. Choose from these code sets for your hospital care claims, as appropriate:

• 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...) through 99223 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity...)
• 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...) through 99233 (… A detailed interval history; A detailed examination; Medical decision making of high complexity...)
• 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...) through 99236 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity...)
• 99238 (Hospital discharge day management; 30 minutes or less) and 99239 (… more than 30 minutes)

The differences in these codes go beyond the numbers, explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med Group in Pittsburgh.

“It is important to note that the levels are very different based on the type of service you are providing. Initial inpatient visits require a lot of work and documentation whereas subsequent visits are, by nature of the service, less involved,” she explains.

Look for Potential Payer Policy Differences in Contracts

The rules on the CPT^® books for hospital care are pretty straightforward, and most payers will follow them exactly as they’re laid out in the code book. There is a chance, however, that certain payers have rules on hospital care coding that differ slightly from the ones CPT^® puts forth.

“All payers have their own rules. Most are common for all contracted providers. However, there may be specific rules for specific providers governed by the contract situation the payer and the provider enter,” explains Hauptman. “Some payers rely heavily on Medicare’s rules, while others use them as a guide and then make theirs more or less stringent.”

“It is always best practice to check with patient’s insurance carrier to determine if they have particular rules on hospital coding,” confirms Brink.

Use Documentation to Demonstrate Medical Necessity

You should always do your best to use the documentation on hospital care claims to fully illustrate each encounter and the patient’s condition throughout the stay.

“Medical necessity is always your overarching criteria,” according to Hauptman. “We should expect to see the documentation paint a picture of how the patient is doing from the time of admission compared to the current visit; the discharge planning should start upon admission; the progress of the patient should be clear; and the work the provider did to determine the best plan should be well illustrated within the note.”

Also remember that the history and exam are important. “So the documentation needs to illustrate everything learned and done for and to the patient in order to substantiate the appropriate service level/type,” she continues.

Best bet: “Follow the E/M documentation and coding guidelines for each level of service that a provider performs and documents. You cannot code what is not documented,” says Brink.