Medicare Compliance & Reimbursement

Question: We are revisiting our coding policies and wondered about choosing the right E/M codes for inpatient care. Do we use the same criteria as we do for choosing outpatient E/M services?

Louisiana Subscriber

Answer: No. Even though the Centers for Medicare & Medicaid Services (CMS) made significant strides in updating outpatient evaluation and management (E/M) codes in 2021, those changes didn’t translate to inpatient E/M codes.

Reminder: The inpatient care codes 99221-99223/99231- 99233 (Initial/Subsequent hospital care, per day, for the evaluation and management of a patient …) and 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date …) were not revised in 2021. While you still have the choice to determine the level of inpatient and office/ outpatient E/M codes based on time, the documentation and calculation of time requirement for inpatient codes still follow 1995/1997 E/M documentation guidance. Also, the level of hospital care cannot be determined on medical decision-making (MDM) alone.

You must continue to determine the level of inpatient care using the three key components of history, examination, and MDM. For 99221-99223 and 99234-99236, that means determining the level of care using all three elements; for 99231-99233, two out of the three elements are necessary. As always, the elements “must meet or exceed the stated requirements to qualify for a particular level of E/M service,” per CPT^® guidelines.

Use this example to refresh your inpatient coding memory: Your ophthalmologist admits a patient to the hospital. On the day of admission, the provider performs a detailed history, a detailed exam, and exercises moderate-complexity MDM based on multiple diagnoses and a moderate risk of complications associated with the patient’s problems.

Based on this, you can assign an inpatient hospital care level of 99221. While the moderate MDM exceeds the code requirements, the detailed history and exam only meet them and do not allow a higher-level code.

Heads up: CPT^® will eventually revise these codes in the way they have revised 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). In the meantime, to use the inpatient codes correctly, you’ll need to follow the current inpatient E/M coding guidelines.