Frequently Asked Questions (FAQs) in Hospital Medicine

Frequently Asked Questions (FAQs) in Hospital Medicine

1. What are the performance and documentation requirements for Inpatient Discharge Day Management services (99238/99239)?

a. The hospital discharge day management codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms. No documentation guidelines were developed specifically for discharge services. There must be a face to face encounter on the date of discharge. If there is no face to face encounter, a service cannot be billed. Ref: CPT Assistant January 1998.

2. What is the definition of a face to face encounter for Discharge Day Management?

a. A face-to-face encounter is defined as: obtaining a history from the patient OR performing an examination OR counseling the patient.

3. Must I document time for Inpatient Discharge Day Management codes 99238/99239?

a. When using Discharge Day Management code 99239 (greater than 30 minutes), TIME MUST BE DOCUMENTED in the medical record to support your use of the code. Documentation of time is not required when billing for code 99238 (less than 30 minutes), but is recommended to maintain consistency in reflecting work effort.

4. How should I document my time for Discharge Day Management code 99239?

a. The preferred method is to make the very last sentence in your hospital Discharge Summary state something similar to “I spent XX minutes coordinating the discharge of this patient”. Alternatively, you may document your time in the progress note by using a statement similar to “Discharge time equals XX minutes” or indicate the appropriate time in your progress note template, where applicable.

5. What if I performed my Initial Hospital Care service before midnight, but the patient wasn’t admitted to Inpatient status until after midnight?

a. Unfortunately, in this scenario, no service can be billed as you performed the Initial Hospital Care prior to the admission date. Per guidelines, the admission should start at the date and time the order to admit is written in the chart. Our admission and discharge dates, as well as place of service, must match the hospital. An Initial Hospital Care service should not be initiated until the patient status has been confirmed as Inpatient. Occasionally, hospital case management or admissions personnel may need to be contacted to correct the patient admission date (in the hospital records) to match the physician order as errors sometimes occur.

6. How do I code if the patient’s admission date was before midnight, but I did not see the patient until after midnight?

a. No service can be coded for the actual date of admission (before midnight); code the appropriately documented Initial Hospital Care code (99221-99222-99223) on the date you actually performed the face to face encounter and provided the service.

7. Can I use the term “non-contributory” to describe the Family History?

a. No. When the Past, Family or Social History has the terms “non-contributory” or “negative”, they are not considered appropriately documented-such documentation would not indicate that the provider actually addressed the issues. It must be clear that the history element was discussed with the patient or obtained from another source. “Negative” statement alone is not best practice comment should specify what is negative about the inquiry.

8. What should I document to describe the Family History?

a. Any one of the following may be used to describe Family History: Health status or cause of death of siblings, parents and/or children, Hereditary or high risk diseases, or specific diseases related to the chief complaint, present illness or Review of Systems. If it is negative, best practice documentation would be “reviewed and negative” versus “negative” alone-reviewed being the pivotal term to demonstrate that you did the work.

9. How should I document the Review of Systems?

a. Those systems with positive or negative responses should be individually documented. For the remaining systems, a finishing statement such as “all other systems were reviewed and negative” or “the rest of the ROS is otherwise unremarkable” or “rest of ROS is otherwise negative” is permissible. In the absence of such a notation, 10 systems must be individually document when coding Moderate or High Initial Inpatient or Initial Observation services.

10. What if I’m unable to obtain the patient’s Past, Family or Social History and Review of Systems due to the patient’s condition?

a. CMS guidelines state that if the provider is unable to obtain a history (or element of the history) from the patient or other source, the medical record should describe the patient’s condition or other circumstances that precluded obtaining a history. In other words, you must document why you were unable to obtain the history, using a statement similar to “history unobtainable due to severe dementia”. If the History caveat is invoked, the history qualifies as a Comprehensive history.

11. How many physical exam organ systems must be documented to support an Initial Hospital Care code 99221-99222-99223 and Initial Observation Care 99218-99219- 99220?

a. Per the 1995 CMS Documentation Guidelines, a 99221/99218 requires the performance and documentation of 5-7 organ systems; 99222/99219 and 99223/99220 requires the performance and documentation of at least 8 organ systems.

12. How many physical exam organ systems must be documented to support Subsequent Hospital Care codes 99231-99232-99233 and Subsequent Observation Codes 99224-99225-99226?

a. Per the 1995 CMS Documentation Guidelines, 99231/99224 requires the performance and documentation of 1 organ system; 99232/99225 requires 2-4 and 99233/99226 requires the performance and documentation of 5-7 organ systems.

1. Must a patient be in a designated Observation area in order to bill for Observation status?

a. No. Observation is a status, not a location. The patient can be residing anywhere in the hospital and qualify for Observation services.

13. If a patient is admitted to Observation on day one, then admitted to Inpatient status on day 2, can I bill both an Initial Observation Code (99218-99219-99220) and an Initial Inpatient Care code (99221-99222-99223) for the differing dates of service?

a. Yes, if you perform and document both services. You must meet the documentation requirements for both-essentially 2 History & Physicals must be created. Elements of the History do not need to be re-documented if you refer to the previously documented Initial Observation Care service with a statement similar to “the history obtained on {date} was reviewed and there are no changes.”

14. How do I bill for the second day of Observation for a 3 day stay?

a. CPT guidelines state that you must use the Subsequent Hospital Observation Care Services codes 99224-99225-99226 for the second Observation day (if the patient is not being discharged).

15. What drugs does Medicare consider as High risk in the Table of Risk-Drug therapy requiring intensive monitoring for toxicity?

a. Drugs that have a narrow therapeutic window and a low therapeutic index may exhibit toxicity at concentrations close to the upper limit of the therapeutic range and may require intensive clinical monitoring. Drugs meeting this criteria may include: Digoxin, Heparin, Coumadin, Vancomycin, Gentamycin, Chloramphenicol, Phenobarbital, Cytotoxic agents, Insulin Drips, Lithium, and Protease Inhibitors. To consider one of these drugs as a high risk option, we would expect to see documentation in the medical record of drug levels obtained at appropriate intervals. In most circumstances, credit is given for high risk if there is a new order for the drug (initiation or changing of dosage strength where monitoring is required to validate therapeutic levels).

16. What are some other High risk options that should be considered with patients being managed in the Observation or Inpatient setting?

a. The Medicare Table of Risk describes Acute Renal Failure, Suicidal or Homicidal Ideation, and Receipt of IV Narcotics, An Abrupt Change in Neurological Status as high risk elements. Those elements being used to support the overall Level of Risk must be documented in the note for that date.

17. Does every patient residing in the ICU or CCU automatically qualify for Critical Care (99291/99292)?

a. No. The Critical Care codes are not place of service codes; they are to be used for patients who meet the definition of Critical Care. Many patients are located in the ICU/CCU but are not critically ill. A minimum of 30 minutes must be spent providing Critical Care in order to use the codes. Time MUST be documented in the medical record!

18. Can I bill for Critical Care and another Evaluation & Management service on the same date?

a. Yes, if each service is performed during a separate session and the performance and documentation requirements for both are met. When a hospital inpatient evaluation and management service (E/M) is furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service For example, you round on the patient in the early morning and perform, document and bill a 99233 Subsequent Hospital Care code; later in the day, the patient crashes and you spend 35 minutes providing Critical Care to the patient and document a distinct note that includes the total Critical Care time-In this scenario, you may bill both the 99233 and the 99291. (hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient)

19. What is the minimum time required in order to bill for Critical Care?

a. 99291 (Critical Care, first hour) may be billed for the first 30-74 minutes of Critical Care.

20. Can multiple providers of different groups and/or specialties bill for Critical Care on the same date?

a. Yes, as long as there is medical necessity and the services are not duplicated.

21. Can I bill CPR (92950) in addition to Critical Care?

a. Yes, both can be billed. You may also bill for some arterial line insertions, endotracheal intubation and other significant procedures not considered “bundled” into Critical Care. Remember that time spent performing separately billable procedures must be deducted from your overall Critical Care time.

22. If a PCP requests that I manage a portion of a patient’s medical care or the Hospitalist is asked to perform a consultation on a patient for a specific reason, how should I bill the initial visit?

a. For Medicare (and many other payers), physicians may bill initial hospital care service codes (99221-99223), for services that were previously reported with CPT consultation codes when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination”.

23. What series of codes should I bill when the ED physician requests that I come to the Emergency Department to evaluate a patient for admission and after evaluating the patient, I determine that the patient does not need to be admitted and can be discharged home?

a. If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code 99281-99285. If the patient is admitted to the hospital by the second physician performing the valuation, he or she should bill an initial hospital care code and not an emergency department visit code.

24. How should I code if a patient was admitted by Dr. A and discharged by me (same group) on the same date of service?

a. The Admit/DC Same Date codes 99234-99235-99236 should be billed by the physician who provided the highest level of service on that date if the patient was admitted for a minimum of 8 hours for Medicare patients (7.5 hours is acceptable).. This would generally be the physician who performed and documented the History & Physical. Only 1 Evaluation & Management Service can be billed per date of service per provider and/or group.

25. Are there unique billing requirements if I am a teaching physician working with residents?

a. If you are combining the services provided by a resident with your note, for billing purposes you must append modifier-GC to each CPT code. There must also be the appropriate attestation in the medical record stating that you personally saw and evaluated the patient; you should also include in the attestation your agreement or changes in the patient treatment plan, as well as your discussions with the resident.

26. I saw and evaluated my patient twice today, once in the early morning and again in the late afternoon. I can only bill one Evaluation & Management service per date of service. Is there anything else that I can bill to capture this extra work?

a. Yes, you can use the Prolonged Services codes (Inpatient-99356-99357 & Outpatient 99354-99355) if there was a direct, face-to-face encounter and you have surpassed the time of the Evaluation & Management code by 30 minutes.

27. I am discharging a patient from acute Inpatient and re-admitting to the Skilled Nursing Facility. Can I charge for both an Inpatient Discharge and an Initial Nursing Facility visit?

a. Yes, an Inpatient Discharge Day Management code (99238/99239) may be billed for the Inpatient Discharge and an Initial Nursing Facility code (99304-99305-99306) can be billed for the SNF admission as long as your documentation supports both services.


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