Public Policy

Demystify Admissions

Physicians may encounter patients in various ways during the first few days of a hospitalization: admission services, consultations, and medical-surgical co-management.

Submitting claims for these services is often inconsistent and inaccurate because billing education is not a standard part of medical education.

In an attempt to clarify the rules and reduce frustration, I will address billing, coding, and reimbursement guidelines for each type of initial hospital encounter over the next several issues.

Code of the Month Initial Hospital Care

99221: Initial hospital care, per day, for evaluation and management of a patient that requires:

  • A detailed or comprehensive history;
  • A detailed or comprehensive examination; and
  • Straightforward or low complexity medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

99222: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Moderately complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

  • A comprehensive history;
  • A comprehensive exam; and
  • Highly complex medical decision making.

Counseling and/or coordination of care with other providers or agencies are offered consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Note: These codes are used for new or patients. The physician does not have to spend the associated “typical” visit time with the patient to report an initial hospital care code. Time is only considered when more than half the visit is spent counseling/coordinating patient care. See Section 30.6.1C (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) for more information about reporting visit level based on time.

Definition

Initial Hospital Care (IHC) comprises all services related to the patient’s admission to an acute care facility. An acute care facility is any that registers inpatients but does not have a corresponding Current Procedural Terminology (CPT) code category for claim reporting. Acute care facilities also include “partial hospitals.”

For example, admissions to inpatient rehabilitation are reported with IHC codes 99221-99223, while nursing facility admissions have a designated category and are best reported with CPT codes 99304-99306 for Initial Nursing Facility Care.

Code Use

IHC codes are reported once per hospitalization and reserved for the physician/group assuming primary responsibility for the patient’s care during that time.

If reported more frequently, all claims within the same hospitalization subsequently reported with codes 99221-99223 are denied or rejected pending review of documentation to ascertain the correct service date and responsible party. This is common because physicians confuse code description IHC with its true intent. They mistakenly report these codes for their first inpatient encounter, regardless of the encounter date or the admitting physician/group.

Specialists assisting in the patient’s management and not primarily responsible for the entire hospitalization report the code category that best reflects the performed service and documentation—as long as the selected category requirements are met. The physician selects from either Inpatient Consultation codes 99251-99255 or Subsequent Hospital Care (SHC) codes 99231-99233. Any physician who provides patient services after the initial encounter, including those by the responsible attending physician/group or a specialist concurrently involved in the patient’s care, reports SHC codes for each date in which a face-to-face encounter occurs.

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