In-patient Coding and Billing

1. In-patient Coding and Billing You Better know This�.. N.Buttar MD

2. Initial Hospital Care Three Levels of Services 99221 $91.00 99222 $136.00 99223 $194.00

3. Initial Hospital Care CPT code 99221 99222 99223 History D or C C C EXAM D or C C C MDM SF or LC MC HC Others Low severity Mod severity High severity

4. Initial Hospital Care 99221 Usually the problem requiring care is of low severity. Time spent is 30 minutes at bedside and on the hospital floor/unit. History D or C Examination D or C MDM low complexity or SF

5. Initial Hospital Care New or Established Patient 99221 Initial hospital visit for a healthy 24 year old patient with a thrombosed synthetic arteriovenous conduit. Initial hospital visit for a 14 year old female with infectious mononucleosis and dehydration. Hospital admission, examination and initiation of treatment program for a 67 year old male with uncomplicated pneumonia who requires IV antibiotic therapy. Hospital admission for an 18 month old with 10 percent dehydration. Initial hospital visit for 21 year old pregnant patient(nine weeks gestation) with hyper emesis gravidarum.

6. Initial Hospital Care 99222 Usually problem is of moderate severity Time spent 50 minutes History C Exam C MDM Moderate

7. Initial Hospital Care New or Established Patient 99222 Initial hospital visit for a 61 year old male with history of previous myocardial infarction, who now complains of chest pain. Hospital admission, young adult patient, failed previous therapy and now presents in acute asthmatic attack. Hospital admission of a 62 year old smoker, established patient, with bronchitis in acute respiratory distress.

8. Initial Hospital Care 99223 High severity Time spent 70 minutes History C Exam C MDM High Complexity

9. Initial Hospital Care New or Established Patient 99223 45 year old female who has a history of rheumatic fever as a child and now has anemia, fever and congestive heart failure. 50 year old male with acute chest pain and diagnostic electrocardiographic changes of an acute anterior myocardial infarction. 70 year old male admitted with chest pain, complete heart lock and congestive heart failure. 82 year old male who presents with syncope, chest pain and ventricular arrhythmias. 62 year old female with known coronary artery disease, for evaluation of increasing edema, dyspnea on exertion, confusion, and sudden onset of fever with productive cough.

10. Initial Hospital Care 99223 78 year old male, transfers from nursing home with dysuria and pyuria, increasing confusion and high fever. Hospital admission for a 78 year old female with left lower lobe pneumonia and a history of coronary artery disease, congestive heart failure, osteoarthritis and gout. Hospital admission for a 9 year old with vomiting, dehydration, fever, tachypnea and an admitting diagnosis of diabetic ketoacidosis.

11. Subsequent Hospital Care CPT code 99231 99232 99233 History PF EPF D EXAM PF EPF D MDM SF or LC MC HC Others Recovering Inadequate Unstable or Improving response Significant complication Minor complication

12. Subsequent Hospital Care 99231 Usually the patient is stable, recovering or improving. Time spent 15 minutes History PF Exam PF MDM SF or LC

13. Subsequent Hospital Care 99231 4 year old female, admitted for acute gastroenteritis and dehydration, requiring IV hydration; now stable. 50 year old male with uncomplicated myocardial infarction who is clinically stable and without chest pain. 60 year old female recovering from an uncomplicated pneumonia. 4 year old female admitted for acute gastroenteritis and dehydration, requiring IV hydration; now stable. 50 year old female with resolving uncomplicated acute pancreatitis.

14. Subsequent Hospital Care 99232 Patient responding inadequately to therapy or Developed minor complication Time spent 25 minutes History EPF Exam EPF MDM MC

15. Subsequent Hospital Care 99232 Patient with venous stasis ulcers who developed fever and red streaks adjacent to the ulcer. 54 year old female admitted for myocardial infarction, but who is now having frequent premature ventricular contractions. 17 year old female with fever, pharyngitis and airway obstruction, who after 48 hours develops a maculopapular rash.

16. Subsequent Hospital Care 99232 35 year old drug addict, not responding to initial antibiotic therapy for pyelonephritis. 62 year old female with congestive heart failure, who remains dyspneic and febrile. 20 month old male with bacterial meningitis treated one week with antibiotic therapy; has now developed a temperature of 101.0.

17. Subsequent Hospital Care 99233 Usually patient is unstable or has developed significant complications Significant new problems Time spent 35 minutes History D Exam D MDM HC

18. Subsequent Hospital Care 99233 60 year old female, four days post-uncomplicated inferior myocardial infarction who has developed severe chest pain, dyspnea, diaphoresis and nausea.

19. In-Patient Consultation New or established patient Only one initial consultation per admission is reported by the consultant Request from another provider for opinion and/or advice must be documented in the records Written report back to the requesting doctor Proven by documentation in records Do not use �THANKS FOR REFERRING� Five codes 99251, 99252 99253, 99254 99255

20. In-Patient Consultation 99251 $75.00 99252 $91.00 99253 $126.00 99254 $177.00 99255 $245.00

21. In-Patient Consultation 99251 Usually self-limiting or minor problem Time spent 20 minutes History PF Exam PF MDM SF

22. In-Patient Consultation Consultations 99251 Initial hospital consultation for an orthopaedic patient on IV antibiotics who has developed an apparent candida infection of the oral cavity. Initial in-patient consultation for a 30 year old female complaining of vaginal itching, post-orthopedic surgery.

23. In-Patient Consultation 99252 Problem - Low complexity Time spent 40 minutes History EPF Exam EPF MDM SF

24. In-Patient Consultation Initial In-patient Consultations New or Established Patient 99252 Initial in-patient consultation for recommendation of antibiotic prophylaxis for a patient with a synthetic heart valve who will undergo urologic surgery. Pre-operative in-patient consultation for evaluation of hypertension in a 60 year old male who will undergo a cholecystectomy. Patient had a normal annual checkup in your office four months ago.

25. In-Patient Consultation 99253 Problem � Moderate complexity Time spent 55 minutes History D Exam D MDM LC

26. In-Patient Consultation Initial In-Patient Consultations New or Established Patient 99253 Initial hospital consultation for a 33 year old female, post-abdominal surgery, who now has a fever. Initial in-patient consultation for a 35 year old female with a fever and pulmonary infiltrate following Cesarean section. Initial in-patient consultation for a 53 year old female with moderate uncomplicated pancreatitis.

27. In-Patient Consultation 99254 Problem � moderate to high complexity Time spent � 80 minutes History C Exam C MDM MC

28. In-Patient Consultation 99254 47 yrs old female with progressive pulmonary infiltrate,hypoxemia and diminished urine output.

29. In-Patient Consultation 99255 Problem � moderate to high complexity Time spent � 110 minutes History C Exam C MDM HC

30. In-Patient Consultation Initial In-Patient Consultations New or Established Patient 99255 Initial in-patient consultation for a 50 year old male with a history of previous myocardial infarction, now with acute pulmonary edema and hypotension.

31. Follow � Up Consultations Used in two situations only 1. Initial consultation could not be completed 2. Requested to perform another consult Codes 99261 $35.00 99262 $61.00 99263 $110.00 99264 $150.00 99265 $190.00

32. Observation or In-Patient Hospital CareAdmission and Discharge on Same Day There are three codes: 99234 $175.00 99235 $240.00 99236 $290.00

33. Observation or In-Patient Hospital CareAdmission and Discharge on Same Day 99234 History D or C Exam D or C MDM SF or LC Usually presenting problem is of low complexity

34. Observation or In-Patient Hospital CareAdmission and Discharge on Same Day 99235 Usually presenting problem is of moderate complexity History C Exam C MDM MC

35. Observation or In-Patient Hospital CareAdmission and Discharge on Same Day 99236 Presenting problem � high complexity History C Exam C MDM High complexity

36. Hospital Discharge Service 99238 30 minutes or less $88.00 99239 More than 30 minutes $120.00 Discharge Services - Appropriate final exam of the patient - Discussion of hospital stay - Instructions for continuity of care to all relevant caregivers - Preparation of discharge records, prescriptions and referral forms

37. Consultations According to AMA � Principles of CPT Coding If a physician sends a patient to another physician for specialized care, which is not in her/his domain, and the physician to whom the patient is referred does not communicate, his/her opinion or advice to the requesting physician, THEN THIS IS NOT A CONSULT

38. Critical Care Service It is a direct delivery by a physician or physicians of medical care for critically ill patients Critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration For example, - CNS failure - Cardiac failure shock - Acute respiratory failure - Renal, hepatic or metabolic failure

39. Critical Care Services Critical care may be provided on multiple days, even if there is no change in the treatment plan, provided the patient�s condition continues to require the level of physician�s attention. Critical care services only qualifies for both illness/injury and treatment meet the requirement Patient being in critical area only does not qualify for critical care billing Services for patient who is in critical care unit but not critically ill, use appropriate E and M codes Critical care and EM services can be provided to the same patient by the same physician on the same day

40. Critical Care Services Services may not be continuous Time spent should be devoted to that patient only Time should be recorded in the patient�s records For example, - Time spent on floor or unit - Reviewing test results or imaging studies - Discussions with medical staff and other providers - Documentation of care. - Collecting information from family members - Discussion of prognosis and treatment options

41. Critical Care Services Time spent outside the hospital or off the unit may not be recorded Time spent performing separately reportable procedures or services should not be reported as critical care time

42. Critical Care Services Services provided to report critical care are: Chest x-ray Pulse oximeter/blood gases Information data reported on computer for example, ECGs, blood pressure or labs Gastric intubation Temporary transcutaneous pacing Vent management Vascular access procedures Any Services performed which are not listed above should be reported separately

43. Critical Care Services 99191 $263.00 99192 $140.00

44. Critical Care Services Critical care codes - > 30 minutes E/M codes - 30-74 minutes 99291 - 75-104 99291 X1 and 99292 X1 - 105-134 99291 X1 and 99292 X2 - 135-164 99291 X1 and 99292 X3 - 164-194 99291 X1 and 99292 X4 - 194 and longer 99291 X1 and appropriate 99292

45. Critical Care Services In-Patient neonatal and pediatric critical care services - Reported if patient qualifies for critical care services - Not dependent on time - Not dependent on type of unit Age less than 31 days - 99295 initial day care - 99296 subsequent day care Age 31 days to 24 months - 99293 initial day care - 99294 subsequent days More than 24 months - 99291 and 99292

46. Critical Care Services Initial day critical care code 99295 can be used in addition to codes 99360, 99436 or 99440 99360 - present for delivery < 30 minutes 99436 - attendance at delivery and initial stabilization of the newborn 99440 - newborn resuscitation 31500 - Endotracheal intubation Subsequent care once patients are not critical; > 2500 grams 99298, 99299 < 2500 grams 99231- 99233

47. Newborn Care Codes 99431 - History and physical for normal newborn infant in the hospital 99432 - History and physical of a newborn outside the hospital 99433 - Subsequent hospital care days 99435 - History and physical on newborn discharged on the same day 99436 - Attendance at delivery and initial stabilization 99440 - Newborn resuscitation For newborn discharge on a separate day use 99238 or 99239

48. Newborn Care Codes 99431 $112.00 99433 $59.00 99435 $112.00 99436 $112.00 99440 $200.00

49. Prolonged Physician Services These codes are used for prolonged service involving direct patient contact (face-to-face) beyond the usual IN-PATIENT and OUT-PATIENT services This is reported in addition to other E & M services Out-patient codes 99354 - 30-60 minutes time 99355 - Each additional 30 minutes In-Patient codes 99356 - 30-60 minutes time 99357 - Each additional 30 minutes

50. Labor and Delivery codes 59409 Vat delivery only $1284.00 59410 Vag delivery and post-partum care $1400.00 59425 Ante-partum care w/o delivery 4-6 visits $475.00 59426 Ante-partum care >6 visits $800.00 59430 Care after delivery $163.00 59510 C/S ,Pre and post-natal care $2200.00 59514 C/S only $1500.00 99514,82 C/S assistance $150.00 59515 C/S and post-partum care $1700.00