Hospital Medicine

Billing basics - admits, subsequent care and discharge

I. Problem/Challenge.

Hospitalists must bill the appropriate charge for each documented service based on the 1995 or 1997 Documentation Guidelines for Evaluation & Management Services.

II. Identify the Goal Behavior

Hospitalists must document admission, subsequent care and discharge notes in order to record pertinent facts, findings and observations about an individual’s health history, communicate to other health care providers, accurately record the time course of events, and review tests and data. In the evaluation of documentation for billing purposes, three key components are reviewed: history (history of present illness (HPI), review of systems (ROS), past medical, family and social health history (PMFSH), exam (as either body areas/organ systems or bulleted items) and decision-making (diagnosis/treatment, review of data, risk of complications).

Admit (CPT* 99221-99223)

The initial admit charge includes key components from history, physical exam and decision-making. Time can be used to select the level of service when more than 50% of the required time is spent with the patient counseling or coordinating care.

Subsequent care (CPT 99231-99233)

Subsequent care charges include key components from at least two of the three areas of history, physical and decision-making. Time can be used to select the level of service when more than 50% of the required time is spent with the patient counseling or coordinating care.

Discharge (CPT 99238 and 99239)

On the date of discharge, the physician must document having seen the patient and suggest that they are ready for discharge. Time differentiates between 99238 and 99239. If more than 30 minutes were spent performing discharge related tasks AND this time requirement was document in the chart, then 99239 should be used.

Billing based on time

“If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to the following: prognosis, differential diagnosis, risks/benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”

* CPT refers to “current procedural terminology” codes.

III. Describe a Step-by-Step approach/method to this problem.

INITIAL ADMIT (CPT 99221-99223)

There are three key components evaluated to determine the appropriate CPT code. These are:

History

History includes the chief complaint, the HPI or status of chronic conditions, the ROS and PMFSH.

  • HPI: Elements of the history of present illness (quality, location, duration, severity, timing, context, modifying factors, associated signs/symptoms) OR the status of chronic medical conditions (i.e. diabetes mellitus, hypertension, chronic pulmonary obstructive disease etc.)

  • ROS: Constitutional, ear, nose and throat (ENT), eyes, cardiovascular, skin/breast, respiratory, endocrine, gastroenterology, genitourinary, hematologic/lymphatic, mental status, neurology, psychology, allergy/immunology

  • PMFSH

Exam

Exam includes documentation of affected body parts or related organ systems.

Note: There are 2 guidelines (1995 and 1997) in use to determine the level of exam. For the sake of simplicity, this chapter refers only to the 1995 guidelines. The 1995 guidelines require a certain number of body areas or organ systems be examined. To simplify even further, a reference is only made to the number of organ systems required to be examined.

Medical decision-making

Medical decision-making is based on the number of diagnoses or problems, review of data and the risk of complications.

  • Diagnosis/problem status: In general you get 1 point for each problem, 2 points for worsening problems, 3 points for new problems and 4 points for new problems with additional work-up planned. 4 points = “extensive” and associated with a “high” level of decision-making.

  • Data: In general you get 1 point for each lab ordered/reviewed and 2 points for reviewing an image/EKG yourself. You must document that you personally viewed an image/EKG. 4 points = “extensive” and associated with a “high” level of decision-making.

  • Risk of complications, morbidity and/or mortality: There is a long list of what is low, moderate or high risk. Some common high-risk problems are: 1. Abrupt change in mental status. 2. Imaging with contrast. 3. Esophagogastroduodenoscopies (EGDs)/colonoscopies. 4. Intravenous (IV) pain medications. 5. Medications requiring monitoring (e.g. coumadin). 6. Change in code status. 7. Severe exacerbation of a chronic problem.

How to choose a level

A simplified approach is to document the following for all admissions and then choose a level based on time or complexity.

  • Chief complaint

  • 4+ point HPI

  • 10+ ROS

  • PMSFH

  • 8+ organ system exam

Then choose level 1-3 by time or complexity.

  • Level 1: Low or 30 minutes

  • Level 2: Moderate or 50 minutes

  • Level 3: High or 70 minutes

Level 1 admit (CPT 99221)

For a level 1 admit you must document the key components of:

  • History: 4+ HPI, 2+ ROS and 1 PMSFH

  • Exam of the affected body area or related organ system: 2+ organ systems

  • Decision making (2 of 3): 1+ diagnosis, 0+ data/tests reviewed, minimal risk

Or, if billing based on time, document the total time (more than 30 minutes) for the encounter and that more than 50% of this time was face-to-face with the patient OR another health care provider. You must document the topic of discussion (i.e. prognosis, diagnosis, risks of therapy, goals of care).

Level 2 admit (CPT 99222)

For a level 2 admit you must document the key components of:

  • History: 4+ HPI, 10+ ROS and 2+ PMSFH

  • Exam of the affected body area or related organ system: 8+ organ systems

  • Decision making (2 of 3): 3+ diagnosis, 3+ data/tests reviewed, moderate risk

Or, if billing based on time, document the total time (more than 50 minutes) for the encounter and that more than 50% of this time was face-to-face with the patient OR another health care provider. You must document the topic of discussion (i.e. prognosis, diagnosis, risks of therapy, goals of care).

Level 3 admit (CPT 99223)

For a Level 3 admit you must document the key components of:

  • History: 4+ HPI, 10+ ROS and 2+ PMSFH

  • Exam of the affected body area or related organ system: 8+ organ systems

  • Decision making (2 of 3): 4+ diagnosis, 4+ data/tests reviewed, high risk

Or, if billing based on time, document the total time (more than 70 minutes) for the encounter and that more than 50% of this time was face-to-face with the patient OR another health care provider. You must document the topic of discussion (i.e. prognosis, diagnosis, risks of therapy, goals of care).

See Table I for the required elements decided by each level of coding.

Table I.

Required elements by level of coding
Level 1 (CPT 99231) Level 2 (CPT 99232) Level 3 (CPT 99233)
History CC4 HPI or 3 chronic2 ROS1 PMFSH CC4 HPI or 3 chronic10+ ROS3 PMFSH CC4 HPI or 3 chronic10+ ROS3 PMFSH
Physical >2+ organ systems ≥8 organ systems ≥8 organ systems
Decision-making* Diagnosis: 1 pointData: 0 pointsRisk: Minimal Diagnosis: 3 pointsData: 3 pointsRisk: Moderate Diagnosis: 4 pointsData: 4 pointsRisk: High
Or time 30 minutes 50 minutes 70 minutes

SUBSEQUENT CARE (CPT 99231-99232)

Level 1 subsequent care (CPT 99231)

For a level 1 subsequent care you must document two of the three key components of:

  • History: 1 HPI

  • Exam of the affected body area or related organ system: 1+ organ systems

  • Decision making (2 of 3): 1+diagnosis, 0+ data/tests reviewed, minimal risk

Or, if billing based on time, document the total time (more than 15 minutes) for the encounter and that more than 50% of this time was face-to-face with the patient OR another health care provider. You must document the topic of discussion (i.e. prognosis, diagnosis, risks of therapy, goals of care).

Level 2 subsequent care (CPT 99232)

For a level 2 subsequent care you must document two of the three key components of:

  • History: 1 HPI, 1 ROS

  • Exam of the affected body area or related organ system: 2+ organ systems

  • Decision making (2 of 3): 3+diagnosis, 3+ data/tests reviewed, moderate risk

Or, if billing based on time, document the total time (more than 25 minutes) for the encounter and that more than 50% of this time was face-to-face with the patient OR another health care provider. You must document the topic of discussion (i.e. prognosis, diagnosis, risks of therapy, goals of care).

Level 3 subsequent care (CPT 99233)

For a level 3 subsequent care you must document two of the three key components of:

  • History: 4 HPI, 2 ROS and 1 PMFSH

  • Exam of the affected body area or related organ system: 4+ organ systems*

  • Decision making (2 of 3): 4+diagnosis, 4+ data/tests reviewed, high risk

Or, if billing based on time, document the total time (more than 35 minutes) for the encounter and that more than 50% of this time was face-to-face with the patient OR another health care provider. You must document the topic of discussion (i.e. prognosis, diagnosis, risks of therapy, goals of care).

*There is ambiguity in the guideline regarding the number of organ systems required to differentiate between levels 2 and 3 subsequent care exams. Depending on the auditor assigned to your region, the number of organ systems expected for a level 3 exam may vary between 2-4 organ systems. To avoid potential denials, we suggest completing/documenting at least a 4-organ system exam to satisfy the requirements for level 3 subsequent care exams.

See Table II for the required elements for subsequent care decided by each level of coding.

Table II.

Required elements by level of coding

DISCHARGE (CPT 99238, CPT 99239)

Discharge (CPT 99238)

There are no required elements for documentation, however documentation of an appropriate history and exam on the date of discharge is required. Total time spent on discharge related elements was less than 30 minutes.

Discharge more than 30 minutes (CPT 99239)

A note on the date of discharge must document an appropriate history, exam AND that more than 30 minutes were spent on discharge related elements.

IV. Common Pitfalls.

You must state why you are seeing the patient in each note. The note must be able to standalone.

Billing based on time must state how many minutes were spent and what you were doing.

Use the -25 modifier (significant, separately, identifiable E&M service) on dates you do your routine rounding and perform a procedure. For example, if you do a paracentesis and a level 2 subsequent care, you bill 99232-25 and 49080.

Two physicians from the same billing group cannot submit similar bills on the same date. For example, Dr. Hospitalist A saw the patient at 4am and submits a subsequent care bill then Dr. Hospitalist B sees the patient at 1pm the same day. Hospitalist B cannot submit an additional subsequent care bill.

Academic hospitalists

Use the “-GC” modifier if the “service has been performed in part by a resident under the direction of a teaching physician”.

You must “link” your note to the intern/resident note and clearly state that you saw and examined the patient, reviewed and agreed with the plan as stated or made corrections as needed.

V. National Standards, Core Indicators and Quality Measures.

1995 and 1997 Documentation Guidelines for Evaluation & Management Services.

VI. What’s the evidence?

"Department of Health and Human Services, Centers for Medicare and Medicaid Services: Evaluation and Management Services Guide".

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