Evaluation and Management - Inpatient Setting

Initial hospital care is reported for a patient who is being admitted to the hospital as an inpatient. The level of service is decided based on the three major key components of history, examination, and medical decision-making.

There are divided into three types.

1. Inpatient Admit or Initial Care - 99221,99222 & 99223
2. Subsequent Hospital or Follow Up - 99231, 99232 & 99233
3. Discharges - 99238 & 99239

Guidelines

Do not report another E/M service along with the inpatient admission code even though if the patient is seen by the same physician for a different reason on the same day.

E.g., 

The physician sees the patient in the ED and after a thorough examination, decides to admit the patient to the hospital.

Report only the appropriate level of inpatient admission code and the ED service is considered the part of admission services when the same service is rendered by the same provider.

If the admission is on a subsequent date from an ED service, both the services can be reported respectively. 

Same day Admission and discharge refer below CPT codes,

• 99234 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A detailed or comprehensive history, A detailed or comprehensive examination; and straightforward or of low complexity of MDM
• 99235 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and moderate complexity of MDM
• 99236 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and High complexity MDM

Additional Information

The selection of a level of E/M service depends mainly on the three major components: 

• History, Examination, and Medical Decision Making (MDM). 
• The other components that might affect the decision-making are the nature of presenting the problem, time, coordination of care, and counseling.

History consists of four components: Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), and Past Family and Social History (PFSH).

Physical Examination: Physical examination is the examination of the organ systems or different body areas relevant to the current disease/disorder.

MDM -Medical Decision Making: After gathering information, the clinician must decide what to do. That thinking process, which takes into account risk factors, is MDM.

It has three components like,

• A number of diagnosis and treatment options.
• The amount and/or complexity of data reviewed.
• The risk of complications, morbidity, and/or mortality involved.

Tips

The admitting physicians can be reported with modifier "AI" for CPT 99221 to 99223 when the patient has "Medicare and Medicare HMO's" insurances since Medicare & HMO's plan would not be covered Consultation services hence Consulting physician can be reported the admit CPT's.

When more than one admits service is billed within the same inpatient setting, the modifier "AI" is denoted as " Principal physician" it will help the insurance to identify the admitting physician's name vs Consulting Physician's names.


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