A 17-year-old with a history of major depressive disorder who is new to the hospitalist service is being transferred out of the pediatric intensive care unit (PICU) after an intentional Benadryl overdose in a suicide attempt.

You review her labs from this morning showing that her electrolytes are normal. You review her pregnancy test and urine drug screen which are both negative. You review the nursing note from this morning which states she is alert, oriented, and calm and her parents are at the bedside. You interpret her electrocardiogram (EKG) tracing and calculate her QTc to be back to normal at 420.

She remains actively suicidal and will require transfer to an inpatient psychiatric facility following the hospitalization per your discussion over secure texting with the social worker. After discussing her management with the PICU physician over the phone, you accept the patient for transfer out of the PICU.

What level of billing does this qualify for?

This patient would qualify to be billed as an initial hospital care level 3 (99223). Although this patient has already been in the hospital for several days, because this patient is new to your service/group then you can bill for a history and physical (H&P) initial encounter. A full H&P must be documented, though billing depends only on the medical decision-making (MDM) or time so extensive documentation is not required, only what is medically indicated. The MDM is a level 3 as the patient has an acute problem with a threat to life/bodily function (actively suicidal with risk to life if discharged) which could also be considered a severe exacerbation of chronic illness (major depressive disorder with suicide attempt). You have reviewed several labs and notes as outlined above as well as independently interpreted an EKG. You have discussed management with an independently licensed health care practitioner (medical social worker and PICU physician).

Tip

For patients coming out of ICU who are new to the hospitalist service during this admission, you can bill for initial hospital care H&P instead of just doing a subsequent day encounter.

Dr. Hadley is an internal medicine and pediatric hospitalist, division chief, acute care pediatrics at Corewell Health/Helen DeVos Children’s Hospital, and assistant professor of internal medicine and pediatrics, at Michigan State University College of Human Medicine in Grand Rapids, Mich.