Hospitalist Coding and Billing (For Dummies)

Judith Hooffstetter, MD

Hospitalist

Objectives

Describe basics of coding and billing

List documentation requirements for E/M levels

Explain new consultative codes

Anatomy of a Charge Card

H&P OBS Subsequent F/U

Admitting

99221 99218 99231 AI

99222 99219 99232

99223 99220 99233

DX ICD-9 Code

Acute on Chronic CHF 428.23

A fib 427.31

DMII Uncontrolled 250.0

Hypothyroid Stable 246.9

COPD 496.0

ICD-9 and CPT Relationship

CPT codes explain WHAT service was performed (level of visit or procedure)

ICD codes explain WHY the service was performed (the diagnosis)

ICD-9

Classification based system that groups data into broad categories

Required by the World Health Organization for reporting mortality data for comparison across countries.

ICD-9 CM is a modification of the code and has been used in the US since 1979.

Anatomy of ICD-9 CM

Have 3,4 or 5 numeric or alpha numeric codes

17 main division of chapters and then further broken down into code sections, code categories, code subcategories and code subclassifications.

The more numbers, the more specific

427427.4

427.41

Cardiac dysrhythmia

Ventricular fibrillation and flutter

Ventricular fibrillation only

Current Procedural Terminology

(CPT)

CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer.

CPT Codes for Hospitalists

Admit and Consult Codes99221- 99223

Subsequent Follow Up 99231-99233

Critical Care Codes99291-99292

Extended Time Codes99356-99357

Discharge Codes99238-99239

How You Get Paid!!

Admission Codes for Hospitalists CMS

99221 – 99223

+

AI (admission modifier)

Elements for E&M visits (How you document for the level)

History – CC – HPI– ROS – PFSH (past, family, social history)•

Exam – number of organ systems

Decision making – #diagnoses or management options – Amount of data/complexity – risk level to patient

Inpatient Level of Care

Key Components

99221 99222 99223

Patient History Detailed Comprehensive

Comprehensive

Patient Exam Detailed Comprehensive

Comprehensive

Medical Decision Making (MDM)

Low Moderate High

For H&P 3 of 3 key elements need to be met

Subsequent Level of Care

Key Components

99231 99232 99233

Patient History Problem focused

Expanded Problem Focused

Detailed Interval

Patient Exam Problem focused

Expanded Problem Focused

Detailed

MDM Straightforward

Moderate High

Subsequent Care requires 2/3 elements

History Matrix

Type of History

HPI ROS FH/SOC Hx

Problem focused

Brief (1-3 elements)

n/a n/a

Exp Problem Focused

Brief (1-3) Problem Pert.(1 system)

n/a

Detailed Extended (4 elements or status of 3 chr

Extended (2-9 systems)

Pertinent (1 element)

Comprehensive

Extended Comprehensive (10 system)

Complete 3/3

ROS

Must Note Pertinent Positives and Negatives in at least 10 systems for Comprehensive

Can no longer say all ROS negative (Can refer to check list on written guide)

Can say unable to obtain from patient (if patient obtunded etc).

Organ Systems (1997 Guidelines)

Cardiovascular

Respiratory

Ear, Nose, and Throat

Eye

Genitourinary

Hematologic/Lymphatic/Immunologic

Musculoskeletal

Neurological

Psychiatric

Skin

Patient Exam

Type of Exam Required PE

Problem Focused 1 – 5 bullets (or one body system or organ system)

Expanded Problem Focused 6 bullets (2-4 body areas or organ systems)

Detailed At least 2 bullets from specified systems or 12 bullets (5-7 body areas or organ systems)

Comprehensive 18 elements with at least 2 from each system (8+ body areas or organ system)

Medical Decision Making Matrix

Type of Decision Making

Number of Diagnosis

Amount and complexity of data

Risk of Complication or Morbidity or Mortality

Straightforward

Minimal (≤1) Minimal (1) or none

Minimal

Low Limited (2) Limited (2) Low

Moderate Multiple (3) Moderate (3) Moderate

High Extensive (≥4) Extensive ≥4 High

MUST MEET 2/3 COMPONENTSFinal MDM requires that 2 of 3 above components are met or exceeded

Amount and complexity of data

Action Points

ReviewAnd/or order clinical test (labs)

1 point

Review and/or order of radiology

1 point

Review and/or order of medical test (vaccines, echo, ekg, pft)

1 point

Discussion of test with performing MD

1 point

Independent review of test 2 points

• Old records or hx from another person and summarizing

2 points

Moderate Complexity

One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast

Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness

Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors

High Complexity

One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

Acute or chronic illnesses or injuries that pose a threat to life or bodily function,

An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory loss

Cardiovascular imaging studies with contrast with identified risk factors

Elective and emergency major surgery

Parenteral controlled substances or drug therapy requiring intensive monitoring for toxicity

Pearls

Action Level

Prescription drug management moderate

2+ stable chronic illness moderate

Abrupt MS change (seizure, TIA)

high

1 chronic illness w/severe exacerbation, progression

high

Make DNR high

Cardiovascular imaging studies with contrast with identified risk factors

high

Emergent major surgery high

Parenteral pain medication high

Subsequent Level of Care

Key Components

99231 99232 99233

Patient History Problem focused

Expanded Problem Focused

Detailed Interval

Patient Exam Problem focused

Expanded Problem Focused (6)

Detailed (12)

MDM Straightforward

Moderate High

Subsequent Care requires 2/3 elements

Time Based Coding for Subsequent Care

When counseling/coordination of care is > 50% of service

AND

When TIME based code would be higher level of service

Time Based Code

CPT CODE Time

99231 15 minutes

99232 25 minutes

99233 35 minutes

Inpatient Consults

Request for consult must be documented by requesting and completing physician

Consulting physician must document opinion and/or advice (send cc to requesting physician)

Document the problem for which YOU are seeing the patient (to prevent concurrent care denials)

Document time = total time

Consults Codes (CMS)

99221- 99223

Consult Codes

No longer use consult codes (99251-99255) for CMS

Can still use them for commercial payers

Use admission codes 99221-99223 (but without the AI modifier).

Can use prolonged service codes (99356-99357) if applicable

Crosswalk for Inpatient ConsultsOld CPT History Exam MDM New code

99253 Det Hx Det Exam At least 2 bullets from specified systems or 12 bullets

Low 99221

99254 Comp Hx 18 elements with at least 2 from each system

Moderate 99222

99255 Comp Hx 18 elements with at least 2 from each system

High 99223

Prolonged Service Codes 99356-99357

Greatly increases reimbursement

Use with 99232 and 99233 when appropriate

Never use with 99231

CAN BE A FLAG FOR MEDICARE AUDITS – so must be used appropriately and well documented

Discharge Codes

99238 Used when time is less <30 minutes

99239Used when time is less >30 minutesMUST DOCUMENT IN YOUR

DICTATION TIME SPENT

TO RECAP

Inpatient Admission Level 3

Component Level 3 Requirements

History Comprehensive

Exam 18 elements with at least 2 from each system

MDM High

Subsequent Visit Level 2

Component Service Required

Exam Problem focused - 6 bullets

MDM Moderate

OR

DOCUMENT BASED ON TIME

Subsequent Visit Level 3

Component Required

Exam 18 elements with at least 2 from each system

MDM High

OR

BASED ON TIME

?