Health Information Management

Understand what codes to assign to report hospitalist services

JustCoding News: Inpatient, May 12, 2010

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by Lois E. Mazza, CPC, PCA

Currently, hospitalist medicine is not a widely recognized specialty, however, professional groups and organizations are gradually emerging, indicating that acceptance by the healthcare community of this field as a specialty will most likely occur in the near future.

Hospitalists are typically internists (i.e., internal medicine specialist) who care for patients while they are hospitalized.

The role of the hospitalist evolved in response to the growing demands of primary care providers, many of whom struggled with over-crowded schedules for their office patients as well as their patients who are admitted to the hospital.

Having hospitalists in the group means fewer trips (if any) for primary care providers to the hospital. Hospitalist services free physicians from having to make extra trips to the hospital during off-hours, as well.

When a patient is admitted in the middle of the night, the hospitalist on duty can handle the entire admitting process, including:

  • Examining the patient
  • Reviewing the patient's history and medications
  • Writing the admission orders
  • Providing counseling
  • Performing any other tasks that would have historically required that primary care physicians to make trips to the hospital or spend many late night hours coordinating their patients’ hospital admissions

Hospitalist medicine is location-centered, similar to emergency medicine or critical care (i.e., intensive care unit-based), as opposed to organ-centered (e.g., cardiology) or age-centered (e.g., pediatrics).

Hospitalists generally do not provide out-of-hospital services, meaning patient’s usually return to their primary care physician for follow-up care after they are released from the hospital.

Coding for hospitalist services

Generally, the types of codes you would report for hospitalists’ services include the following:

  • Hospital inpatient services codes
    • Initial hospital care
    • Subsequent hospital care
    • Hospital discharge services
    • Inpatient consultations
  • Hospital observation services codes
    • Observation care discharge services
    • Initial observation care
    • Observation or inpatient care services (including admission and discharge services
  • Critical care services codes
    • Based on the amount of time spent providing care
    • Patient must be critically ill (e.g., central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory)
    • Diagnosis must reflect critical condition
    • Time charged must be documented in the patients record

Initial hospital care

Coders use these codes to report the first hospital inpatient encounter by the admitting physician for new or established patients.

Sometimes physicians admit patients to the hospital as a result of an encounter at a different site of service. For example, when a physician sees a patient for an office visit and admits the patient that same day, all evaluation and management (E/M) services the physician provided in conjunction with that admission are considered part of the initial hospital care when the physician performs these services on the same date as the admission.

The level of service the admitting physician reports should include the services related to the admission that he or she provided at the other sites of service as well as in the inpatient setting.
Use the following CPT codes to report initial hospital care:

99221: Initial hospital care, per day, for the evaluation and management of a patent, which requires these three key components:

  • A detailed or comprehensive history
  • A detailed or comprehensive examination; and
  • Medical decision-making that is straightforward or of low complexity

Usually the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

99222: Initial hospital care, per day, for the evaluation and management of a patent, which requires these three key components:

  • A comprehensive history
  • A comprehensive examination; and
  • Medical decision-making of moderate complexity

Usually the problem(s) requiring admission are of low severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223: Initial hospital care, per day, for the evaluation and management of a patent, which requires these three key components:

  • A comprehensive history
  • A comprehensive examination; and
  • Medical decision-making of high complexity

Usually the problem(s) requiring admission are of low severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Subsequent hospital care

All levels of subsequent hospital care (codes 99231–99233) include reviewing the medical record and reviewing diagnostic studies and changes in the patient’s status (e.g., changes in history, physical condition, and response to management) since the last assessment.

Coding scenario: A patient is seen in the office and admitted on the same day. Who reports charges?

Mrs. Lemonjello is seen in her primary care giver’s office. While being evaluated, her physician, Dr. White, decides she must be hospitalized. He sends her to the hospital and informs one of his group’s hospitalists, Dr. Green, that Mrs. Lemonjello will be admitted that day. Dr. White dictates a note that includes a comprehensive history of present illness, and notates that the patient will be admitted that day.

The hospitalist evaluates the patient and writes a note that reflects a comprehensive exam and medical decision-making of high complexity.

The hospitalist, Dr. Green, should report code 99223 (initial hospital care, level three). The level of care Dr. Green reports should also reflect the services Dr. White provided in the office.

Dr. White needs to document notes regarding the services provided. Facilities will ideally have a mechanism in place to capture services rendered by providers that are not ‘reportable.’

Hospital discharge services codes

These codes are time-based (i.e., fewer than 30 minutes or more than 30 minutes).

Documentation needs to include a notation when the service exceeds 30 minutes. Report the following CPT codes to report hospital discharge services:

  • 99238: Hospital discharge day management; 30 minutes or less
  • 99239: Hospital discharge day management; more then 30 minutes

Hospital observation services codes

Use these codes to report E/M services when physicians order observation services for patients. Only the admitting physician may bill observation codes. When attending physicians request services from another physician, the latter should use outpatient codes to bill services rendered to a patient in observation. Guidelines have not yet established “typical times” for observation services.

Report code 99217 (observation care discharge) only when the discharge from observation is on a date other than the initial date the physician ordered observation services. Note the following code description in the 2010 CPT Manual Professional Edition:

99217: Observation care discharge day management (This code is to utilized by the physician 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 the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services 99234–99236 as appropriate].)

Use initial observation care codes (99218–99220) to report all E/M services physicians render to patients in observation. You would also use these codes to report the initial encounter for observation patients whose stays exceed a 24-hour period.

Do not separately report E/M services the physician provides on the same date at a different site.

Coding scenario: A physician orders observation services for a patient on day one. The hospitalist evaluates the patient on day two and discharges the patient on day three. What codes should the provider report for all three days?

Hospitalist Dr. Kraynak orders observation services for Mrs. Scooterbug, who remains in observation for three days.

For day one of observation, Dr. Kraynak should report the appropriate level code from initial observation care codes 99218–99220.

For day two, Dr. Kraynak should report outpatient E/M codes for any evaluations he or she performs on this day.

For day three, the hospitalist should report observation care discharge services code 99217. Use this discharge code for patients who receive observation services and who physicians then discharged on a different day.

Observation or inpatient care services (including admission and discharge services)

Use these codes (99234–99236) for patients in observation as well as for inpatients admitted and discharged the same day.

For patients who receive observation or inpatient care and are discharged on a different date, see codes 99218–99220 and code 99217 or codes 99221–99223 and codes 99238–99239.

Coding scenario: A patient is admitted as an inpatient but leaves later the same day against medical advice. What codes should the provider report?

Hospitalist Dr. Spring admits Mr. Greyfeather as an inpatient. After he moves to his room, Mr. Greyfeather becomes upset and decides to leave the hospital. Dr. Spring notes the patient’s abrupt departure on the history and physical. Dr. Spring should report the appropriate level code(s) (99234–99236) under the heading: Observation or Inpatient Care Services (Including Admission and Discharge Services)

Refer to these codes for patients who are admitted and discharged the same day. Use the codes for patients who receive observation services as well as inpatients who are admitted and discharged the same day.

Critical care services

Report the following CPT codes for critical care services:

  • 99291: Critical care, evaluation and management of the critically ill or injured patient; first 30–74 minutes
  • +99292: Critical care, evaluation and management of the critically ill or injured patient, each additional 30 minutes

Coding scenario: A hospitalist sees the patient in the morning. The patient becomes critical that afternoon. Should the hospitalist submit a critical care code for the same date of service as the inpatient E/M code?

When a patient becomes critical on the same day for which the provider reports an E/M service, the physician may report the E/M hospital visit as well as the appropriate critical care code.

For example, Dr. Brown sees his patient Mrs. Clearwater, the morning of the day he admits her. She is admitted for abdominal pain and weakness. In the afternoon, Mrs. Clearwater begins to experience symptoms of a gastrointestinal bleed and develops critical symptoms. Dr. Brown examines her again, provides critical services and appropriate documentation.

Dr. Brown should report the initial inpatient charge for the level of service provided (99221–99223). For the critical care provided, coders should follow critical care guidelines and report the appropriate critical care codes.

CPT critical care guidelines state, “Critical care and other E/M services may be provided to the same patient on the same day by the same physician.”

Coders who report hospitalist services should have or plan to acquire a clear understanding and knowledge of inpatient E/M service codes, as well as codes for critical care, ED, and observation.

Editor’s note: Lois E. Mazza, CPC, PCA, is a certified professional coder at Lahey Clinic Medical Center in Burlington, MA. E-mail her at Lois.E.Mazza@lahey.org.



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