Briefing: Coding Inpatient Professional Services Date: 21 March 2007 Time: 0900 - 0950

1. Briefing: Coding Inpatient Professional Services Date: 21 March 2007 Time: 0900 - 0950

2. Objectives • Rounds defined • Be aware of E&M coding issues • Be aware consults in the inpatient setting have different rules • Special services defined • Be aware of diagnosis coding • Be aware of procedure coding issues

3. Professional Component • The MHS captures inpatient workload with professional and institutional data. All SADRs generated have a flag that indicates if the patient is inpatient or outpatient • Inpatient rounds are captured in the A MEPRS • Internal Medicine AAAA • Family Practice AGAA • Obstetrics ACCA • An appointment type in DoD information systems (CHCS/AHLTA/P-GUI) is designed to capture professional services delivered in the inpatient environment by the service of the attending provider of record • Attending Service • The medical or surgical service to which the patient is officially admitted via admission or transfer orders

4. Institutional Service • Inpatient services provided by certain personnel are considered institutional service/cost and will not produce an inpatient professional service round • Radiology • Laboratory • Pharmacy • Anesthesiology • These staff members may be included as secondary providers on an ADM encounter involving a privileged provider (e.g., the attending would be the primary provider and a resident would be the secondary provider) • House staff • Technicians • Physician extenders • Non-privileged providers

5. Generation of Rounds • Patient presents to family practice clinic encounter • FP identifies • Abdominal Pain • Fever • FP proceeds with admission • Attending physician is FP

6. Admission Service • 3 key components – DOCUMENTED • 99221 • Detailed – history • Detailed – exam • Lowmed decision making • 99222 • Comprehensive – history • Comprehensive – exam • Moderatemed decision making • 99223 • Comprehensive – history • Comprehensive – exam • High-med decision making

7. Rounds Generation • Rounds are generated by two methods • Automatically • At census hour to the admitting service A MEPRS • Attending provider field must be filled in • Per MHS policy, house staff do not have admitting privileges. If a house staff officer receives an inpatient RNDS, the record needs to be redirected to the attending provider • Manual Creation • Why would you do this? • Interservice transfers • Transfer precipitated by the consult

8. Subsequent Hospital Care • 2 of 3 Key Component DOCUMENTED • 99231 • Problem-focused INTERVAL history • Problem-focused exam • Low med decision making • 99232 • Expanded problem-focused INTERVAL history • Expanded problem-focused exam • Moderate med decision making • 99233 • Detailed INTERVAL history • Detailed exam • High med decision making

9. Discharge Services • Hospital Discharge Services • The hospital discharge day management codes are to be used to report the total duration of time spent by the 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 • 99238 – 30 minutes or fewer • 99239 – more than 30 minutes

10. Admit/Discharge Same Day • The following codes are used to report observation or inpatient hospital care provided to patients admitted and discharged on the same date of service • 3 Key Components DOCUMENTED • 99234 • Detailed or comprehensive history • Detailed or comprehensive exam • Straightforward or low med decision making • 99235 • Comprehensive history • Comprehensive exam • Moderate med decision making • 99236 • Comprehensive history • Comprehensive exam • High med decision making

11. Observation Status • This is an outpatient status • Patients may not be discharged from inpatient status to observation status • These codes are for direct admit to observation status • Patients may go from observation to admit status • 3 Key Components DOCUMENTED • 99218 • Detailed or comprehensive history • Detailed or comprehensive exam • Straightforward or low med decision making • 99219 • Comprehensive history • Comprehensive exam • Moderate med decision making • 99220 • Comprehensive history • Comprehensive exam • High med decision making

12. Observation Care Discharge Services • Observation care discharge of a patient from “observation status” includes final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records • 99217

13. Inpatient Consults • Inpatient Consult • A consult resulting from a request by the attending physician to evaluate or give advice • It may initiate diagnostic or therapeutic services to an inpatient remaining under the care of the attending physician • There is only one inpatient consult code per service per admission • Follow-up inpatient consults from that service are coded with subsequent E&M hospital day codes • There must be a written request in the inpatient record, and a written consult in the inpatient record

14. Inpatient Consult Codes • 3 Key Components DOCUMENTED • 99251 • Problem focused history • Problem focused exam • Straightforward med decision making • 99252 • Expanded problem focused history • Expanded problem focused exam • Straightforward med decision making • 99253 • Detailed history • Detailed exam • Low med decision making • 99254 • Comprehensive history • Comprehensive exam • Moderate med decision making • 99255 • Comprehensive history • Comprehensive exam • High med decision making

15. Critical Care • Determined by condition, not location • I.e., patient location may be intensive care unit • Critical care is the direct delivery by a physician of medical care for a critically ill or critically injured patient • Critical care involves high complexity decision making to assess, manipulate, and support vital system functions • 99291 - First 30 – 74 minutes; “stable” is not sufficient documentation to explain 30+ minutes of service • 99292 – Each additional 30 minutes • Do NOT use for concurrent care

16. Diagnosis Coding • First and subsequent days – code what is addressed during that episode of care (usually rounds are for the entire day, it could be multiple rounds but one code) known at that time • Only code abnormal labs/rads when DOCUMENTED by the provider in the doctor’s note • Rationale • Just like outpatient professional, you code what you know at the encounter • Do not code “rule out,” “suspect,” or any other “questionable” diagnosis • When doing data analysis, the diagnoses associated with the 99221/9922/99223 initial hospital care and 99231/99232/99233 subsequent hospital care will sometimes be symptoms and will frequently be follow up to surgical procedure or fracture aftercare (for example, V54.14 aftercare for healing traumatic fracture of hip) • Collect the progression of the workup and treatments leading to final (principal) diagnoses

17. Example 1 Medicine with or without complications • Admit – Code why (e.g., chest pain) • Do not code the “rule out MI” for the E&M, it is based on the documentation for an initial hospital care • Code the sign and symptom chest pain • Subsequent – Code what was known at time of documentation (e.g., MI) for the E&M • It is based on the documentation for a subsequent hospital care • Discharge – Code principal diagnosis (e.g., MI) for the E&M, it is based on the documented time

18. Example 2 Planned surgical admission • Admission • Code menorrhagia • Hysterectomy (CPT based on documentation) • E&M would be 99499 • Subsequent • Code aftercare ICD • 99024 Global • E&M 99499 • Discharge • Code principal diagnosis (uterine fibroids) • 99024 Global • E&M of 99499

19. Surgical Complication • A complication is an UNEXPECTED issue, that “complicates” normal care for that postoperative time • A fever and pain frequently accompany post operative care as do some “what-could-be-abnormal” laboratory values • Only code something as a complication if the provider specifically documents it as a complication

20. Example 3 Planned surgical admission with complication • Admission • Code menorrhagia • Hysterectomy (CPT based on documentation) • E&M would be 99499 • Subsequent • Code aftercare • 99024 Global • E&M 99499 • Subsequent • Documented “complication,” sequence the complication first, then the aftercare V-diagnosis • Use subsequent hospital care codes 99231-99233 • Discharge • Code principal diagnosis (uterine fibroids) and complications • 99024 Global • E&M of 99499

21. Example 4 Medicine admission with unplanned global surgical event • Admit • Code why (e.g., abdominal pain) • E&M based on the documentation for an initial hospital care 99221-99223 • Subsequent – • Code what was known (e.g., abdominal pain) • E&M based on the documentation for subsequent hospital care 99231-99233 • Operative day • Code the postoperative diagnosis • Code the CPT surgical procedure (appendectomy) • Subsequent • Code aftercare ICD • Code 99024 if no postoperative complications • E&M 99499 • Discharge • Code principal diagnosis appendicitis • Code 99024 • E&M of 99499

22. Diagnosis Coding • Discharge day – Code everything that was addressed during the hospitalization, with the principal diagnosis being the first listed SADR diagnosis • Rationale • When doing data analysis, the diagnoses associated with the 99238/39 discharge hospital care and admit/discharge same day (99234-99236) will feed to the bill

23. MEPRS • THOU SHALL NOT collect inpatient professional services in the B*** MEPRS, except for initial consults • A consult stops being a consult and becomes subsequent hospital care when a definitive diagnosis is made or when the provider assumes responsibility for that medical issue

24. Summary • Rounds – We know what they are • E&M coding issues • Some are 2 of 3 key components • Some are 3 of 3 key components • Be aware consults in the inpatient setting have different rules • Only one consult • Special services defined • Diagnosis coding • Signs and symptoms vs confirmed • Be aware of procedure coding issues • Coded as part of inpatient stay