CODING FAQs-INPATIENT

1. CODING FAQs-INPATIENT Lynn Myers MD, CPC, CHC

2. Inpatient FAQs When do I use the AI (alpha-alpha) modifier? Append this modifier when admitting a Medicare/Managed Medicare patient to an inpatient or nursing facility. This identifies the admitting physician, and distinguishes that physician from consulting physicians that may be using the same codes (99221-99223, for Medicare consultations) Use on initial admission codes, not on subsequent hospital or nursing facility encounter codes http://www.cms.gov/MLNMattersArticles/downloads/MM6740.pdf

3. Inpatient FAQs What codes should be used when patients on Observation status have more than a 24 hour stay? 99224-stable, recovering, improving 99225-responding inadequately to treatment, minor complication 99226-unstable, has developed significant complication or new problem

4. Inpatient FAQs What constitutes Critical Care (99291-99292)? Critical Care is directed at the critically ill/injured patient, which involves high complexity decision making to support vital system function(s) and/or prevent further life threatening deterioration. CNS failure Circulatory failure Shock Renal, Hepatic, Metabolic and/or Respiratory failure Critical Care begins after 30 minutes-if < 30 minutes, report subsequent care codes Document the critical nature of your encounter, and total time spent in the care of the patient during the course of a 24 hour period!

5. Inpatient FAQs What if Critical Care and a Subsequent Hospital Visit occur on the same day? If subsequent hospital visit occurred first, report 99231-99233 with modifier 25 to indicate that this encounter is to be considered for payment as well as the Critical Care code, which occurs later in the day. TIMING OF NOTES IS CRITICAL! If Critical Care encounter occurred first, then consider the total time spent with the patient during the entire day in the choice of Critical Care codes 99291 (30-74 minutes) 99292 (one unit for each additional 30 minutes). Carefully document time spent in each encounter.

6. Inpatient FAQs What other services may be reported in the hospital setting? 49080 Paracentesis 51100 Bladder Tap 62270 Spinal Tap 69210 Ear Lavage -performed by provider, document necessity 92950 CPR (do not add time spent performing CPR in Critical Care time) 93042 Rhythm strip interpretation -document necessity in care plan 97597-97598 Wound debridement; document surface area 99406-99407 Smoking cessation (3-10 minutes or >10 minutes) G0436-G0437 Smoking cessation without symptoms

7. Inpatient FAQs What do I code when I see the patient more than once in a day? Consider all time spent in the care of the patient when choosing level of service, including time spent on the floor/unit. 99231 Typical time is 15 minutes 99232 Typical time is 25 minutes 99233 Typical time is 35 minutes If providing care that is beyond the usual service (documentation is the key), document this time in the medical record and report Prolonged Service: 99356 For the first hour 99357 For each additional 30 minutes

8. Inpatient FAQs What happens when partners see the same patient in the same day? Only one service is reported by the same specialty each day.

9. Inpatient FAQs What is the necessary documentation for a consultation ? Requestors should document that they require the OPINION of a colleague to assess or manage a symptom or exacerbation of a condition. “Request that Dr. Spivey’s opinion regarding labile blood pressure and hyperglycemia.” Responders (the consultants) should document that their OPINION has been requested regarding the symptom or condition. This differentiates the consultation from a transfer of care. “Dr. Zhivago requests my opinion regarding this patient’s labile hypertension and hyperglycemia which are not responding to current treatment.” **Medicare consultations are reported with Initial Hospital Care codes 99221-99223**

10. Inpatient FAQs When the patient is seen in the ER and then admitted to the hospital, are both the ER encounter and the Hospital Admission reported? Report one code per physician per day-in this case, report the hospital admission, taking into account the entire time spent in a day. 99221 30 minutes 99222 50 minutes 99223 70 minutes Report Prolonged Service codes if appropriate 99356 30-74 additional minutes 99357 Each additional 30 minutes

11. Inpatient FAQs What is expected for the subsequent care services? 99231-Patient is stable, recovering, improving. Typical time is 15 minutes, documentation requires 2 of 3 key components 99232-Patient is responding inadequately, has developed minor complication, documentation requires 2 of 3 key components 99233-Patient is unstable, has developed major complication or significant new problem, documentation requires 2 of 3 key components Documentation should utilize these phrases-a list of diagnoses is not sufficient to establish medical necessity of the encounter Codes should decrescendo over the course of the hospital stay.

12. Inpatient FAQs What is required for reporting Discharge Services? Document total duration of time spent for final discharge. Document services provided, including instructions to all relevant caregivers, preparation of discharge records, prescriptions and referral forms. 99238 30 minutes or less 99239 >30 minutes

13. Inpatient FAQs What if the patient is discharged from one facility and admitted to another facility on the same date of service? Report both the discharge from the first facility and the initial admission to the new facility, Documentation should clearly state the reason for the transfer to the new facility. Take care to utilize the correct Place of Service code for each encounter. Services will initially be denied, and documentation will be reviewed to ascertain medical necessity. Claim will be resubmitted for consideration with the progress notes.