Practice Economics

Demystify Admissions


 

Physicians may encounter patients in various ways during the first few days of a hospitalization: admission services, consultations, and medical-surgical co-management.

Submitting claims for these services is often inconsistent and inaccurate because billing education is not a standard part of medical education.

In an attempt to clarify the rules and reduce frustration, I will address billing, coding, and reimbursement guidelines for each type of initial hospital encounter over the next several issues.

Code of the Month Initial Hospital Care

99221: Initial hospital care, per day, for evaluation and management of a patient that requires:

  • A detailed or comprehensive history;
  • A detailed or comprehensive examination; and
  • Straightforward or low complexity medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. 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 patient, which requires these three key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Moderately complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate 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 patient, which requires these three key components:

  • A comprehensive history;
  • A comprehensive exam; and
  • Highly complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Note: These codes are used for new or patients. The physician does not have to spend the associated “typical” visit time with the patient to report an initial hospital care code. Time is only considered when more than half the visit is spent counseling/coordinating patient care. See Section 30.6.1C (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) for more information about reporting visit level based on time.

Definition

Initial Hospital Care (IHC) comprises all services related to the patient’s admission to an acute care facility. An acute care facility is any that registers inpatients but does not have a corresponding Current Procedural Terminology (CPT) code category for claim reporting. Acute care facilities also include “partial hospitals.”

For example, admissions to inpatient rehabilitation are reported with IHC codes 99221-99223, while nursing facility admissions have a designated category and are best reported with CPT codes 99304-99306 for Initial Nursing Facility Care.

Code Use

IHC codes are reported once per hospitalization and reserved for the physician/group assuming primary responsibility for the patient’s care during that time.

If reported more frequently, all claims within the same hospitalization subsequently reported with codes 99221-99223 are denied or rejected pending review of documentation to ascertain the correct service date and responsible party. This is common because physicians confuse code description IHC with its true intent. They mistakenly report these codes for their first inpatient encounter, regardless of the encounter date or the admitting physician/group.

Specialists assisting in the patient’s management and not primarily responsible for the entire hospitalization report the code category that best reflects the performed service and documentation—as long as the selected category requirements are met. The physician selects from either Inpatient Consultation codes 99251-99255 or Subsequent Hospital Care (SHC) codes 99231-99233. Any physician who provides patient services after the initial encounter, including those by the responsible attending physician/group or a specialist concurrently involved in the patient’s care, reports SHC codes for each date in which a face-to-face encounter occurs.

When services begin in one location (e.g., physician’s office, emergency department, or observation) and end with an inpatient admission on the same calendar day, the physician reports only the most appropriate initial hospital care code. It is not necessary for the physician to duplicate the information from the earlier encounter for the admission service. Instead, the physician can forward a copy of the progress note from the earlier encounter to the inpatient chart, along with the documented decision for admission and pertinent information obtained throughout the day. Auditors consider the culmination of all chart entries in a given date when reviewed. When services begin in one location but end with an admission on different calendar day, the physician separately reports each service provided on each date: 99220 on Day 1 and 99223 on Day 2.

Intrafacility Transfers

Patients may receive different components of inpatient services within the same (uninterrupted) episode of care, all within the same building but treated as separate facility admissions (e.g., rehabilitation or long-term acute care).

It is unlikely the attending physician of record during the acute care phase will also be the attending physician during the second phase of care. Should this occur, Medicare contractors and those payers who follow Medicare guidelines permit the attending physician to separately report the acute care discharge (99238-99239) and the secondary admission (99221-99223), but only in the absence of a shared medical record (see Section 30.6.9.1D,www.cms.hhs.gov/manuals/downloads/clm104c12.pdf). If a common chart is used, the physician reports the secondary admission services as ongoing care, using SHC codes 99231-99233 instead.

Similarly, transfers occur within a single phase of care, such as transfers to and from a medical intensive care unit and a standard medical-surgical unit. Such transfers are not treated as separate admissions, and the receiving physician reports only the SHC codes because the IHC service was previously reported by the admitting physician/group. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia.

Code This Case

A hospitalist admits a patient to observation for chest pain to rule out myocardial infarction at 11 p.m. on Day 1.

Early on Day 2, test results, including serial electrocardiograms, cardiac enzyme and troponin levels, and echocardiography, confirm suspicions, and the physician admits the patient for treatment.

The inpatient admission documentation includes a detailed history and exam (because a complete history and exam, along with high complexity decision making, was previously recorded upon admission to observation) and high complexity medical decision-making. What service(s) can the hospitalist report?

The Solution

The hospitalist can potentially report two services because each occurred on a different calendar day; this assumes that the documentation and billing requirements for each service are met. The hospitalist must document the inpatient admission service separately from the observation admission, and only portions of the documentation from the observation admission can be counted toward the inpatient admission information.

The Centers for Medicare and Medicaid Services Documentation Guidelines for Evaluation and Management Services (E/M) is considered the gold standard of E/M resources. It indicates the physician must redocument the history of present illness (HPI), physical exam and medical decision-making (MDM) when referencing encounters from a previous date of service. In other words, the hospitalist can reference, by date, the review of systems and past, family, and social histories without having to redocument these elements. However, the hospitalist must reconfirm the HPI, reperform the physical exam, reconsider the plan of care, and redocument each of these items in a currently dated progress note.

Assuming separate notes were appropriately documented with the levels of history, exam and MDM indicated in the scenario above, the hospitalist reports 99220 for chest pain (ICD-9-CM 786.50) on Day 1 and 99221 for anterolateral myocardial infarction (ICD-9-CM 410.01) on Day 2.

Although the documentation for the inpatient admission service included high-complexity MDM, the hospitalist selects the visit level supported by each of the key components (i.e., history exam, and decision making). The lowest component determines the visit level; a detailed history and exam with high complexity MDM only supports 99221.

In contrast, if the hospitalist documented a single, yet cumulative, note with a comprehensive history and physical exam, and high complexity MDM on Day 2, he/she may report only the inpatient admission service (99223) unless the note identified each date and their corresponding components of documentation.

More information regarding the key components and guidelines for E/M documentation is available at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.—CP

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