basic inpatient e/m coding training

Basic Inpatient E/M Coding Training

Office of Regulatory Affairs & Compliance

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Outline

This training only covers the basic elements of coding for inpatient evaluation and management (E/M) services, specifically initial hospital visits, subsequent hospital visits, discharge services, observations, inpatient consultations, coding based on time, and prolonged services.

Components of E/M Services Inpatient E/M Inpatient Services

Initial Hospital Visits Subsequent Hospital Visits Hospital Discharge Services Hospital Observation Services Inpatient Consultations When to Use Time Based Coding Prolonged Services

Most Frequently Used Modifiers Selecting, Sequencing and Linking Diagnosis Codes Completing Fee Tickets Teaching Physician Attestations for E/M Services

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Components of E/M Inpatient Services

Inpatient E/M services have the same basic components as outpatient E/M.

Below are the basic components:

History Chief Complaint History of Present Illness (HPI) Review of Systems (ROS) Past Medical, Family, Social History (PFSH)

Examination

Medical Decision-Making (MDM) Number of diagnoses or management options Amount and/or complexity of data reviewed or ordered Risk of complications and/or morbidity or mortality

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Overview of Inpatient E/M Leveling

The codes listed in the left hand column require 3 of 3 components be met or exceeded.

History Exam Medical Decision-Making Time Based

Code Type PF EPF Detailed Comp PF EPF Detailed Comp S L M H Avg. Time

99221 Initial

Hospital

Visit

X X X X 30

99222 X X X 50

99223 X X X 70

99218 Observation

Services

X X X X NA

99219 X X X NA

99220 X X X NA

99234 Hospital Observation or Inpatient Care Services

(Including Same Day Admission and

Discharge)

X X X X NA

99235 X X X NA

99236 X X X NA

99251 Inpatient

Consultations

X X X 20

99252 X X X 40

99253 X X X 55

99254 X X X 80

99255 X X X 110

PF = Problem Focused EPF = Expanded Problem Focused C = Comprehensive S = Straightforward L = Low M = Moderate H = High

Notes: Codes 99221, 99218, and 99234 can either have straightforward or low medical decision-making. See slide 21 for information on when and how to code based on time.

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Overview of Inpatient E/M Leveling

The codes listed in the left hand column require 2 of 3 components be met or exceeded; 1 of the 2 must be medical decision-making.

History Exam Medical Decision-Making Time Based

Code Type PF EPF Detailed Comp PF EPF Detailed Comp S L M H Avg. Time

99231 Subsequent (Follow-up)

Visit

X X X X 15

99232 X X X 25

99233 X X X 35

PF = Problem Focused EPF = Expanded Problem Focused C = Comprehensive S = Straightforward L = Low M = Moderate H = High

Notes:

Code 99231 can either have straightforward or low medical decision-making.

See slide 31 for information on when and how to code based on time.

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Overview of Inpatient Visits

Initial hospital care:

*Code 99221, 99222 or 99223

Subsequent follow-up or encounter by provider other than admitting

physician:

Code 99231, 99232 or 99233

Inpatient consults:

Code 99251, 99252, 99253, 99254, or

99255

Hospital Discharge Day Management:

Code 99238 or 99239

Notes: See slides 4-5 and 8-17 for more information on when and how to use these codes. *For Medicare and CareLink patients, see slides 7 and 16 for information on when and how to use these codes because these payors have different coding guidelines. Prior to admission, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).

Admission & discharged on same calendar date:

*Code 99234, 99235 or 99236

Admit to hospital as inpatient

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Overview of Inpatient Visits - Medicare & CareLink

Admit to hospital as inpatient

Admission < 8 hours:

Code 99221, 99222 or 99223

Admission > 8 hours but < 24 hours & discharged on same calendar date as

admission:

Code 99234, 99235 or 99236

Admission > 24 hours:

Code 99221, 99222 or 99223

Subsequent visit by admitting physician or visit by provider other

than admitting physician:

Code 99231, 99232 or 99233

Inpatient consults:

Code 99251, 99252, 99253, 99254, or 99255

Hospital Discharge Day Management:

Code 99238 or 99239

Notes: See slides 4-5 and 8-17 for more information on when and how to use these codes.

Prior to admission, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).

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Initial Hospital Visits

Codes 99221-99223 are used by the admitting physician to report initial services to hospital inpatients. These codes are often referred to as the “Admit” codes.

Notes: Only one physician can be the admitting physician and only the admitting physician

can use codes 99221-99223. All other providers should bill the inpatient E/M codes that describe their participation

in the patient’s care (i.e., subsequent hospital visit or inpatient consultation). When performed on the same date as the admission, all other outpatient services

provided by the physician in conjunction with that admission are considered part of the initial hospital care.

If the patient is seen in the office on one day, and admitted on the next day (even if <24 hours have elapsed) by the same physician, code both the office visit and initial hospital visit.

Code 99221-99223 +

99238-99239

99221-99223 +

99231-99233 +

99238-99239

Type Initial Hospital Visit +

Hospital Discharge Day Management

Initial Hospital Visit +

Subsequent Hospital Visit +


Duration of Service 1st calendar day - admitted

+

3rd calendar day - discharged

1st calendar day - admitted

+

2nd or subsequent calendar days

+


Comments Code both services Code all services

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Initial Hospital Visits

History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i.e., 3 out of 3 same level or higher).

Code History Exam Medical Decision Making Comments

99221 Detailed or comprehensive

Detailed or comprehensive

Straightforward or low Usually presenting problem(s) are of low severity

99222 Comprehensive Comprehensive Moderate Usually presenting problem(s) are of moderate severity

99223 Comprehensive Comprehensive High Usually presenting problem(s) are of high severity

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Initial Hospital Visit - Clinical Example

The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code.

The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem.

Initial hospital visit for a 50 year old patient with lower quadrant abdominal pain and increased temperature, but without septic picture.

Based on this example, what code should be assigned? For the answer, see the next slide.

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Initial Hospital Visit - Clinical Example

Based on the example in the preceding slide, the service provided and

documented should support initial hospital visit code 99222.

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Subsequent Hospital Visits

Codes 99231-99233 can be used by any provider to report subsequent inpatient services.

Two out of 3 components of history, exam, and medical decision-making must meet or exceed the same level to assign a code (1 of the 2 has to be medical decision-making).


99231 Problem focused Problem focused Straightforward or low Usually patient is stable, recovering, or improving

99232 Expanded problem-focused

Expanded problem-focused

Moderate Usually patient is responding inadequately to therapy or experiencing a minor complication

99233 Detailed Detailed High Usually patient is unstable or has developed a significant complication or significant new problem

Notes: The descriptors for these codes include the phrase “per day,” meaning care for the

day. If Provider A sees the patient in the morning and Provider B, who is covering for

A, sees the same patient in the evening, the notes for both services are combined and only one subsequent hospital visit is coded.

If two physicians see the patient and they are in different specialties and are seeing the patient for different reasons (i.e., different diagnosis), then both may bill a subsequent hospital visit based on that physician’s note and the medical necessity of the service.

Select a code that reflects all services provided during the date of service.

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Subsequent Hospital Visits - Clinical Example



Subsequent hospital visit for 55 year old male with severe chronic obstructive pulmonary disease and bronchospasm; initially admitted for acuter respiratory distress requiring ventilator support in the ICU. The patient was stabilized, extubated and transferred to the floor, but has not developed acute fever, dyspnea, left lower lobe rhonchi and laboratory evidence of carbon dioxide retention and hypoxemia.

Based on this example, what code should be assigned. For the answer, see the next slide.

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Subsequent Hospital Visits - Clinical Example



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Observation or Inpatient Hospital Care(Including Admission and Discharge Services)

Codes 99234-99236 are used by a provider to report observation or inpatient hospital care

services provided to patients admitted and discharged on the same date of service.




Straightforward or low Usually problem(s) requiring admission are of low severity

99235 Comprehensive Comprehensive Moderate Usually problem(s) requiring admission are of moderate severity

99236 Comprehensive Comprehensive High Usually problem(s) requiring admission are of high severity

Notes: When performed on the same date as the admission, all other outpatient services

provided by the physician in conjunction with that admission are considered part of the initial hospital or observation care.

When a patient is admitted to observation or inpatient care and discharged on a different date, see slides 4, 6-11 and 17 for information on when and how to use the initial hospital care codes 99221-99223 and discharge management codes 99238-99239, or slides 18-25 on when and how to use hospital observation codes 99218-99220 and observation care discharge code 99217.

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Observation or Inpatient Hospital Care – Medicare and CareLink

Codes 99234-99236 are used by a provider to report: Admitting and discharging a patient on the same calendar day for >8 hours but <24 hours, or Placing a patient under observation and discharging the patient on the same calendar date for >8 hours but <24 hours




Straightforward or low Usually problem(s) requiring admission are of low severity

99235 Comprehensive Comprehensive Moderate Usually problem(s) requiring admission are of moderate severity

99236 Comprehensive Comprehensive High Usually problem(s) requiring admission are of high severity

Notes: In addition to meeting the documentation requirements for history, exam and medical

decision-making, documentation in the medical record should include: Statement that the stay for observation care or inpatient hospital care involved

eight hours, but less than 24 hours. Admission and discharge notes written by the billing provider. Personal documentation by the billing provider indicating presence and face-to-

face services were provided.

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Codes 99238-99239 are used to report the total duration of time spent by the provider for final hospital discharge services.

History Comments

99238 Hospital discharge day management, 30 minutes or less Face-to-face time between the attending and the patient

99239 Hospital discharge day management, more than 30 minutes

Notes: Only one hospital discharge service is coded per patient, per hospital stay. Only the attending physician of record reports the discharge day code. Discharge service is billed on the date of the actual visit by the provider even if the

patient is discharged on a different calendar date. Includes, as appropriate:

Final patient exam Discussion of the hospital stay Instructions for continuing care Preparation of discharge records, prescriptions, and referral forms

Total time of the visit must be documented to support code assigned. All other providers performing a final visit should code subsequent hospital care

(99231–99233).

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Hospital Observation Services

Initial observation care:

Codes 99218, 99219 or 99220

Then use discharge code

99217

Then admit as inpatient:

Code 99221-99223 (see slides 8-11)

Notes: See slides 20-25 for more information on when and how to use these codes. *For Medicare and CareLink patients, see slides 19 and 21 for information on when and how to use these codes because these payors have different coding guidelines. Prior to observation, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).

Admit to Observation

Status*

Subsequent visit by admitting physician or

visit by another provider

Code 99212, 99213, 99214, or 99215

Outpatient consultation: Code

99241, 99242, 99243, 99244, or

99245Admission & discharged on same calendar date:

*Code 99234, 99235 or 99236

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Hospital Observation Services – Medicare and CareLink

In Observation < 8 hours and discharged same calendar date:

Code 99218, 99219 or 99220

In Observation > 8 hours but < 24 hours and discharged

same calendar date: Code 99234, 99235 or 99236

(see slide 15)

In Observation > 24 hours: Code 99218, 99219 or 99220

In Observation > 48 hours: Code 99218, 99219 or 99220

then 99212-99215

When discharged, use observation care

discharge day management: Code

99217

If admitted, use initial hospital visit:

Code 99221, 99222 or 99223 (see slides 8-11)

Notes: See slides 20-25 for more information on when and how to use these codes. Prior to observation, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).

Admit to Observation

Status

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Hospital Observation Services

These codes are used to report a patient placed under observation and include initiation of observation status, supervision of care, and periodic assessments.

Notes: Billed only by the physician who admitted the patient to observation and was responsible for the

patient during his/her stay. All other providers should bill the outpatient E/M codes that describe their participation in the

patient’s care (i.e., office and other outpatient service codes or outpatient consultation codes).

Code 99218-99220 +

99217

99218-99220 +

99212-99215 +

99217

99218-99220 +

99212-99215 +

99221-99223

Type Initial Observation Care

+

Observation Care Discharge Services

Initial Observation Care

+

Established Patient, Office or other Outpatient Visit

+


Initial Observation Care

+

Established Patient, Office or other Outpatient Visit

+

Initial Hospital Visit

Duration of Service 1st calendar day - placed under observation

+

2nd calendar day - discharged

1st calendar day - placed under observation

+

2nd calendar day - subsequent service

+


1st calendar day - placed under observation

+

2nd calendar day - subsequent service

+

3rd calendar day - admitted to inpatient status

Comments Code both services Code all services Code all services

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Hospital Observation ServicesHistory, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i.e., 3 out of 3 same level or higher).

Notes: The descriptors for these codes include the phrase “per day”, meaning care for the

day. Select a code that reflects all services provided during the date of the service. The observation record for the patient must contain dated and timed physician’s

admitting orders regarding the care the patient is to receive while in observation, and progress notes prepared by the physician while the patient was in observation status. This information is in addition to any record prepared as a result of an emergency department, outpatient clinic, or nursing facility encounter.

In rare instances when a patient is held in observation status for more than two calendar dates, the physician must code subsequent services before the discharge date using outpatient/office visit codes (99212-99215).


99218 Problem focused Problem focused Straightforward or low Usually patient is stable, recovering, or improving

99219 Expanded problem-focused

Expanded problem-focused

Moderate Usually patient is responding inadequately to therapy or experiencing a minor complication

99220 Detailed Detailed High Usually patient is unstable or has developed a significant complication or significant new problem

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Code 99217 is used to report discharge services of a patient in observation status.

History Comments

99217 Observation care discharge day management Face-to-face time between the attending and the patient

Notes: Billed only by the physician who was responsible for observation care during this stay. Discharge service is billed on the date of the actual visit by the provider . Includes:

Final patient exam Discussion of the hospital stay Instructions for continuing care Preparation of discharge records, prescriptions, and referral forms

All other providers performing a final visit should use outpatient/office visit codes (99212-99215).

Do not bill the hospital observation discharge management code (99217) if patient was Admitted to inpatient status, use codes 99221-99223. See slide 8-11 for more

information on when and how when and how to use these codes. Placed under observation and discharged on the same calendar date, use codes

99234-99236. See slide 15-16 for information when and how to use these codes.

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Hospital Observation During A Global Surgical Period The global surgical fee includes payment for hospital observation (codes 99217,

99218, 99219, 99220, 99234, 99235 and 99236) services unless specific requirements are met.

Observation services may be paid in addition to the global surgical fee only if both of the following requirements are met: The hospital observation service meets the criteria needed to justify billing it with

modifiers: 24 - Unrelated E/M service by the same physician during a post-operative

period 25 - Significant, separately identifiable E/M service by the same physician on

the same day of a procedure or other service 57 - Decision for major surgery

The hospital observation service furnished by the surgeon meets all the criteria for the hospital observation code billed.

See slide 35 for information on when and how to use modifiers with E/M services.

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How to Use Observation Codes - Examples

Date 9/189/18

Medicare & CareLink9/19 9/20

Admitted to Observation by Provider A on 9/18 at 1AM; seen and discharged by Provider A at 7 AM on 9/18

99234-99236

(Provider A)

99218-99220

(Provider A)

Admitted to Observation by Provider A on 9/18 at 1AM; seen and discharged by Provider A at 9/18 4PM

99234-99236

(Provider A)

99234-99236

(Provider A)

Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider B 9/18 at 3 PM; seen and discharged on 9/19 at 7 AM by Provider A

Note: Provider A is from a different specialty than Provider B and the service was not a consultation.

99218-99220 (Provider A)

99212-99215 (Provider B)

99218-99220 (Provider A)

99212-99215 (Provider B)

99217

(Provider A)

Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider A on 9/19; and, seen and discharged by Provider A on 9/20

99218-99220

(Provider A)99218-99220

(Provider A)

99212-99215

(Provider A)

99217

(Provider A)

Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider A on 9/19; and, admitted by Provider A to inpatient status 9/20

99218-99220

(Provider A)99218-99220

(Provider A)

99212-99215

(Provider A)

99221-99223

(Provider A)

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Inpatient Consultations

Codes 99241-99245 are used to report consultations provided to hospital inpatients.

History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i.e., 3 out of 3 same level or higher).


99251 Problem focused Problem focused Straightforward Usually presenting problem(s) are self limited or minor

99252 Expanded problem-focused Expanded problem-focused Straightforward Usually presenting problem(s) are of low severity

99253 Detailed Detailed Low Usually presenting problem(s) are of moderate severity

99254 Comprehensive Comprehensive Moderate Usually presenting problem(s) are of moderate to high severity

92255 Comprehensive Comprehensive High Usually presenting problem(s) are of moderate to high severity

Notes: An inpatient consultation may only be billed once per consultant, per admission. Additional follow-up visits after the initial inpatient consultation are billed using the

subsequent hospital care codes (99231-99233). See slide 12-14 for information on when and how to use these codes.

A request to take care of the problem is a referral, and should be coded with subsequent hospital care code 99231-99233. See slide 12-14 for more information on when and how to use these codes.

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Inpatient Consultations

These requirements must be met and supported by documentation in the patient’s inpatient medical record to code and bill a consultation. The service is provided by a physician or qualified non-physician provider whose

opinion or advice regarding evaluation and/or management of a specific problem is requested by provider (excludes residents, fellows, and interns) due to the consultant’s expertise in a specific medical area beyond the requesting provider’s knowledge; and,

The request for a consultation including the name of the requestor and the need or reason for the consultation must be documented by the consultant in the inpatient’s medical record; and,

After the consultation is provided, a written report of the consultant’s findings, opinions, and recommendations is documented in the inpatient record for the requesting provider to use in the management of and/or decision making for the patient; and,

Intent is to return the patient to requesting provider for ongoing care of the problem. During the service, the consultant may:

Perform or order diagnostic tests, or Initiate a treatment plan, including performing emergent procedures.

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Examples of Disposition Boxes for Consultation Services Templates

Here are examples that you may include in your documentation templates to support your intent to return the patient to the requestor.

❑ Return to requesting provider with recommendations and treatment options.

❑ Return to requesting provider’s care with final recommendations after completion of

additional diagnostic testing.

❑ Return to requesting provider’s care with final recommendations after evaluation of

trial of therapeutic regimen.

❑ Will follow for X problems in parallel with requesting provider if provider agrees.

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Inpatient Consultations - Clinical Example



Initial inpatient consultation for a 72 year old male with emergency admission for possible bowel obstruction.


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Inpatient Consultations - Clinical Example



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When to Use Time Based Coding In an inpatient setting, when more than 50% of the total visit time by the teaching

physician is counseling and/or coordinating the patient’s care, the time used to code must be provided at the patient’s bedside and/or on the patient’s hospital floor or unit.

When coding based on time, the teaching physician may not: Add time spent by the resident in the absence of teaching physician to face-to-

face time spent with the patient by the teaching physician with or without the resident present .

Count time counseling or coordinating the patient’s care after leaving the patient’s floor or after beginning to care for another patient.

In addition to documenting history and/or physical exam provided, the documentation should include: Total visit time and time spent counseling and coordinating care, and, Description of the medical decision making and counseling discussion and/or

activities coordinated. Examples of documenting support for coding based on time based:

“I spent a total of 30 of 45 minutes on the floor coordinating David’s care and in discussion with David regarding…”

“30 of 40 minutes of visit at Mary’s beside discussing ….with Mary and her family was spent discussing…”

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Prolonged Services

Codes 99356 and 99357 can be used to report inpatient services involving direct (face-to-face) care provided beyond the usual E/M service.

Code E/M Type Typical Time for Code Threshold Time to Bill Code 99356 Threshold Time to Bill Code 99357

99221

Initial Hospital Visit

30 60 105

99222 50 80 125

99223 70 100 145

99231

Subsequent Visit

15 45 90

99232 25 55 100

99233 35 65 110

99251

Inpatient Consultation

20 50 95

99252 40 70 115

99253 55 85 130

99254 80 110 155

99255 110 140 185

Note: See slides 33-36 for information on when and how to use these codes.

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When to Use Prolonged Service Codes

Only count the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical/average time of the E/M visit code billed for the same date of service. See slide 32 for typical and threshold times and applicable E/M services.

Must be 30 minutes or more beyond the typical time assigned to the E/M level coded Example: Average time for 99232 = 25 minutes, so a minimum of 55 minutes would be

required to also bill 99356. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes

beyond the final 30 minutes is not reported separately. Prolonged service of less than 30 minutes total duration on a given date is not separately

reported because the work involved is included in the total work of the E/M codes. Cannot bill prolonged services:

Based on time spent reviewing charts or discussing a patient with house medical staff without direct face-to-face contact with the patient, waiting for test results, changes in the patient’s condition, end of a therapy, or use of facilities

Without first coding an inpatient E/M service on the same date of service If the total duration of direct face-to-face time does not equal or exceed the threshold time

for the level of E/M service the provider is billing When the E/M service is selected based on time, prolonged services may only be reported as the

companion code with the highest code level in that family of codes (i.e., 99223, 99233, or 99255). See slide 8-14 and 26-30 for information on when and how to bill codes based on time.

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Documentation for Prolonged Services

Documentation is required in the medical record about the duration and content of the medically necessary E/M service and prolonged services billed.

The start and end times of the visit must be documented in the medical record along with the date of service.

The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the provider personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.

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Prolonged Services - Clinical Example



A 34 year old primigravida presents to hospital in early labor. Admission history and physical reveals severe preeclampsia. Physician supervised management for preeclampsia, IV magnesium initiation and maintenance, labor augmentation with pitocin, and close maternal-fetal monitoring. Physician face-to-face involvement includes 40 minutes of continuous bedside care until the patient is stable, then is intermittent over several hours until the delivery.


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Prolonged Services - Clinical Example



37

Inpatient Modifiers

These are the most frequently used modifiers with inpatient E/M services. However, there may be others. See TrailBlazers’ Modifier manual for a complete listing of other modifiers at http://www.trailblazerhealth.com/Publications/Manuals/.

24 - Unrelated E/M service by the same physician during a post-operative period.

25 - Significant, separately identifiable E/M service by the same physician on the same day of a procedure.

57 - Decision for major surgery.

GC - Service performed in part by a resident under direction of a teaching physician.

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Tips on Selecting Diagnosis Codes

This information will assist in the selection of diagnosis codes used to bill an E/M service.

Diagnosis codes: Describe the condition(s) that prompted the visit and support the medical necessity

and level of service coded. Must be supported by documentation in the current note. Are coded to the highest degree of specificity (e.g. renal failure vs. chronic kidney

disease, Stage III). May be taken from final assessment or chief complaint. Can be based on signs/symptoms if unable to make definitive diagnosis during the

visit. Cannot be coded for conditions documented as “rule out… probable... possible…

questionable…”. Include secondary conditions affecting treatment during the current visit. Diagnosis codes are not assigned when a diagnosis is mentioned in the history and is

not addressed, or there is no indication in the current visit note that the diagnosis affected care.

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Tips on Sequencing Diagnosis Codes

All diagnosis codes must be sequenced (1,2,3, etc.) on the fee ticket. Sequencing on the fee ticket should follow the same sequence as the diagnosis are

documented in the current visit note. First-listed code:

Chief complaint (i.e., diagnosis, condition, problem, or other reason for the visit such as chemotherapy) chiefly responsible for the service provided.

If the reason for the visit was for multiple complaints and each was addressed as supported by documentation,

The complaint that was most time consuming due to evaluation and/or management is sequenced first; and,

The remaining complaints are sequenced thereafter based on evaluation and/or management.

Additional codes: Newly diagnosed codes that were evaluated and/or treated during the current

service. Co-morbid conditions that coexist at the time of the service and influence,

require, or affect patient-care or treatment as supported in documentation. Selecting a diagnosis without sequencing the code is not acceptable.

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Example of Linking Diagnosis Codesto E/M Services and Procedures

Assessment: Codes:

1.Asthma with acute exacerbation2.Native vessel coronary artery disease3.Pilondial cyst without abscess

1.493.022.414.013.685.1

E/M Service: Subsequent hospital visit 99232-25 1. 493.022. 414.043. 685.1

Procedures: • Incision and drainage of pilondial cyst, simple

10080 3. 685.1

Notes: When an E/M service and a procedure are coded for the same visit, diagnosis codes

must be linked to both the E/M service and the procedure. Applying the appropriate modifier to the E/M and procedure code support the medical

necessity of both services. See slide 37 for information on when and how to assign E/M modifiers.

The patient was admitted 2 days ago with acute exacerbation of asthma and native vessel CAD. Today, a painful pilondial cyst was also evaluated and the cyst was incised and drained. Notes supporting the subsequent hospital visit and I&D were fully documented in the patient’s medical record.

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Completing A Fee Ticket

Select E/M level

Select additional service or procedure codes as applicable

Select, sequence, and link diagnosis codes for each E/M and procedure coded

Select modifiers

Sign the paper fee ticket or authenticate the electronic fee ticket

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Documenting a Teaching Physician Attestation for E/M ServicesThe teaching physician does not have to re-perform and re-document the entire E/M

service to bill. However, the teaching physician, at minimum, must personally document

an attestation to supplement the resident’s documentation.

The attestation includes a statement that the teaching physician: Personally performed the service, or was physically present during the key or

critical portions of the service when performed by a resident; Participated in the management of the patient; and, Reviewed the resident’s note. The name of the resident should be included in

the attestation.

When properly attested, the resident’s documentation and the faculty’s documentation can be used by the teaching physician to determine the level of E/M service billed and support medical necessity.

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Examples of Teaching Physician Attestations for E/M Services Examples of acceptable attestations:

“I saw and evaluated the patient. I agree with the findings and plan of care documented in Dr. Resident’s note.”

“I saw the patient with Dr. Resident and agree with his findings and plan.” “I saw the patient and discussed the patient with Dr. Resident and agree with the

note except that the findings are more consistent with…. Will begin ….”

Examples of unacceptable attestations: “Discussed with resident and agree.” “Patient seen and evaluated.” “Agree with the above.”

It is also unacceptable for a resident to attest to a teaching physician’s presence and participation in an E/M service. For example, “I saw and evaluated the patient with Dr. Faculty who agrees with

my findings and plan of care.”

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Questions

If you have any questions, please contact:

Your UT Medicine Coder Educator

or

Office of Regulatory Affairs & Compliance at 567-2014

basic inpatient e/m coding training

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