Wiki Inpatient E/M

lhoot

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Getting some new responsibilities at work and need some assistance in E/M coding for inpatient visits. If anyone has any good resources on doing these, I would be very grateful. In the meantime, I have a couple questions.

Patient has been admitted for several days. Progress note lists a plethora of conditions being treated. The primary reason for admission is acute on chronic chf, for which diuresis treatment is being done. A particular visit note, day 7, states patient denies any acute complaints. Medication management noted. Also noted is that the patient will need to continue inpt admission while continuing diuresis.

1. When assessing the risk for this visit, would this be high or moderate? Patient is not as critical as she was on admission and seems to be getting better, but needs a little more time for treatment. The need for inpt services would generally indicate the condition or treatment to be high risk, so would the need to be admitted or continue admission be inherently high risk?

2. For number and complexity of problems addressed, 4 conditions would be an extensive level of diagnosis/management options. If the patient has 9 conditions (several chronics) being addressed/treated/monitored, this would equate to an extensive level, correct?

Thank you in advance for any help.
Laura
 
Just because a patient is in the hospital doesn't mean they are inherently high risk. And even if you have all the elements for a level 3 (99233), that doesn't make it a level 3. There is such a thing as over-documentation. For the 3 levels of inpatient care, remember these things:

Level 1 - patient stable, recovering, or improving. Typical time 15 minutes (hospital floor and bedside combined).
Level 2 - patient responding inadequately to treatment or has developed a minor complication. Typical time 25 minutes.
Level 3 - patient is unstable, or has developed significant complication or significant new problem. Typical time 35 minutes.

So on day 7 if they have no new complaints, they are responding adequately to treatment, etc., then only over-documenting could make them a level 3.

Generally, in the normal course of a hospital stay, you will see the trend down from 3 to 1. Something similar to this: 3, 3, 3, 2, 3, 3, 2, 1, 2, 1, 1, 1 (etc.).
 
That sounds reasonable.
Would the number of conditions being treated have any bearing? For instance a patient being treated for 9 or 10 different conditions, maybe one or two of them are not responding to treatment or have a minor complication. Would this warrant the same level 2 as a patient with 2 or 3 conditions with one not responding to treatment or with a minor complication?
 
My doctor works at an inpatient rehab hospital. Half of the patients have at least 8 conditions present, and another fourth of the patients have around 15 or so. Of those 15 conditions, maybe 3 or 4 are critical. If the patient is in for critical illness myopathy and after-effects of covid, does the fact that they have an artificial hip matter much? Probably not. If they fell and broke a femur, does that artificial hip matter? Yes it does.

Our H&P always lists all of the present conditions. I look to the notes after that to see what the doctor is actively managing. The patient may have well-controlled depression, and the only management of it we're doing is writing the order for a daily antidepressant that he was taking at home. Now if the patient is a new amputee, their mental health is going to be front and center and something we're going to have to keep a close eye on.

I'm not saying don't code them the way you normally would. I'm saying watch for overdocumentation. Particularly with EMR, it's easy to do. When my boss first went back to the rehab hospital, we had a talk about the three levels I mentioned above. Now he ends his daily dictations with a statement on how the patient is doing, such as "the patient is stable and doing well and should be able to be discharged in three days", or "patient is not improving in physical therapy as we had hoped he would; we are meeting with PT and OT in team conference tomorrow", or "patient is declining with frequency of tachycardia increasing; we have may to send him back to the acute hospital if this continues." That way, if I have any doubts about what level I should be billing, I know what the doctor's mindset is.
 
Thank you so much for the insight. Your explanations are definitely making it clearer.

The notes I'm looking at are inpatient acute care progress notes and I'm looking at just individual notes. Plans for some of the conditions are documented well enough that I can tell the physician is planning regular maintenance for the condition, for example when they actually state improved or just that they are continuing home meds and no further monitoring is being done. Other conditions, they'll note they are monitoring or they don't state one way or the other if the patient is improving, stable, or worse, but they are ordering tests/imaging. These are the ones that throw me.

Again, thank you so much for sharing your expertise.
I truly appreciate it.
Laura
 
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