A 38-year-old woman with a history of recurrent urinary tract infections (UTIs) is admitted to the emergency department-run observation unit at a local community hospital for a severe UTI and is started on ceftriaxone. She continues to have fevers associated with nausea and occasional vomiting 24 hours into her observation stay. A CT scan of her abdomen and pelvis demonstrates pyelonephritis. Urine culture is positive for Escherichia coli. The observation physician calls the inpatient physician to discuss the case, as she feels uncomfortable discharging the patient home. She has concerns about antibiotic resistance given the patient’s ongoing fevers and her history of recurrent UTIs treated with numerous antibiotics, as well as concerns regarding adherence to oral antibiotics given her ongoing issues with vomiting. As the inpatient hospitalist physician, you evaluate the patient’s chart, review her labs, look at her CT imaging and ECG yourself, and after a discussion of the expected patient course, decide that admission is appropriate. When you see the patient, she has a temperature of 38.4° C and occasional rigors. You are concerned about ongoing infection and possible bacteremia, so you place an admission order and perform the admission history and physical.

What level of billing does this qualify for?

This would qualify as a level 3 admission (99223). This patient has a severe, complicated UTI which is acutely life-threatening given her ongoing fevers, rigors, and vomiting. This could be documented as a concern for bacteremia or as an inability to tolerate sufficient oral intake. Both would represent acutely life-threatening complications of her condition regardless of the presence of other complications that may be present (acute kidney injury, electrolyte disturbances, liver injury, etc.). Thus, with sufficient documentation, this would count as high complexity under “number and complexity of problems addressed.”  Deciding to admit the patient (having at least a substantial contribution to the discussion or having final decision-making ability) can be documented and counted as a high risk under “risk of complications and/or morbidity or mortality of patient management.” This is possible because patients in observation are considered outpatients and not actually admitted. This same decision could also be documented for patients being admitted from any outpatient space, including the catheterization lab, endoscopy suite, or emergency department.

Tip

Patients with an acutely decompensated chronic medical condition or acute threat to life will often meet the criteria for level-3, initial, inpatient billing (99223) if you document the discussion and the decision to admit the patient inpatient. The documentation of this discussion should be sufficiently robust to determine that you were the final decision maker, why the patient is being admitted, and what clinical criteria you are using to make that determination.

Dr. Gentile is an internal medicine hospitalist, section chief for acute care medicine, associate program director for internal medicine at Corewell Health Western Michigan, and an assistant professor in the department of medicine at Michigan State University College of Human Medicine, all in Grand Rapids, Mich.