Initial hospital care – E&M codes (99221, 99222, 99223) used to report the first hospital inpatient encounter between the patient and admitting physician.

Subsequent inpatient care – E&M codes (99231, 99232, 99233) used to report subsequent hospital visits.

Hospital Discharge Day Management Services – E&M codes (99238, 99239) used to report the work performed to discharge a patient from an inpatient stay.

Admission and Discharge Same Day – E&M codes (99234 – 99236) used to report services for a patient who is admitted and discharged from an observation or inpatient stay on the same calendar date.  Patient’s stay must be a minimum of eight hours in order to bill these codes.

STANDARD

Hospital Initial Inpatient Care

• All three (3) “key” components, history, examination and medical decision-making, must be included in the medical record documentation.
• Initial Hospital Care may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.
• This code includes all services performed at all sites by the admitting physician that relate to the admission.  E&M services provided on the same date in a site other than the hospital that are related to the admission should not be reported separately but documentation by the admitting provider from other E&M services may be combined with the admission documentation to determine the appropriate level of initial hospital care.

Code	History	Examination	Decision Making
99221	Detailed or Comprehensive	Detailed or Comprehensive	Straightforward or Low complexity
99222	Comprehensive	Comprehensive	Moderate complexity
99223	Comprehensive	Comprehensive	High complexity

• Modifier – AI (Principal Physician of Record) should be appended to the initial visit submitted by the admitting provider.  This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.
• Physicians may bill initial hospital care service codes for services that were reported with CPT consultation codes (99251 – 99255) prior to January 1, 2010.  Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.  Physicians may report a subsequent hospital care code for services that were reported as CPT consultation codes (99251 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.  Modifier – AI would not be appended to these codes.

Subsequent Inpatient Care (per day)

• These services require that two (2) of the three (3) “key” components, history, and/or examination and/or medical decision making, must be included in the medical record documentation in order to meet or exceed the criteria for the code.
• Subsequent Hospital Care codes may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

Code	History	Examination	Decision Making
99231	Interval-Problem focused	Problem focused	Straightforward or Low complexity
99232	Interval-Problem focused	Expanded problem focused	Moderate complexity
99233	Interval-Detailed	Detailed	High complexity

• Two different physicians may bill concurrently for subsequent hospital care provided the physicians are from different specialties and are treating different diagnoses.
• All levels of subsequent care include a record review as well as a review of any diagnostic results and changes in the patient’s status since the last assessment by the physician.

Hospital Discharge Day Management Services

• Hospital Discharge Day Management Services are a face-to-face evaluation and management (E/M) service between the attending physician and the patient.
• The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified non-physician practitioner even if the patient is discharged from the facility on a different calendar date.
• Only one hospital discharge day management service is payable per patient per hospital stay.
• Only the attending physician of record reports the discharge day management service.  Physicians or qualified non-physician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range 99231 – 99233) for a final visit.
• Hospital Discharge Day Management Services are used to report the total amount of time spent by the physician for final discharge of a patient.  These codes include, as appropriate:
  • final examination of the patient;
  • discussion of the hospital stay even if the time spent is not continuous;
  • instructions for continuing care to all relevant caregivers; and
  • preparation of discharge records, prescriptions and referral forms.

Code	Description
99238	Hospital Discharge Day Management Services; 30 minutes or less
99239	Hospital Discharge Day Management Services; more than 30 minutes

• Since these codes are time based, it is necessary to document time in the medical record when using code 99239 to reflect service time in excess of 30 minutes.  If time is not documented, 99238 should be coded.
• Only the physician who personally performs the pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service.  The date of the pronouncement shall reflect the date of service on the day it was performed even if the paperwork is delayed to a subsequent date.

Admission and Discharge Same Day

• Service codes 99234 – 99236 are used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service.  The codes should be reported in lieu of those described in Part I of this standard.  All three (3) “key” components, history, examination and medical decision-making, must be included in the medical record documentation.
• When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care codes (99221 – 99223) are used.  The Hospital Discharge Day Management services (99238 or 99239) are not to be reported.
• When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date the Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services) are used.  See table below.

Code	History	Examination	Decision Making
99234	Detailed or Comprehensive	Detailed or Comprehensive	Straightforward or Low complexity
99235	Comprehensive	Comprehensive	Moderate complexity
99236	Comprehensive	Comprehensive	High complexity

• Documentation must support an admission and a discharge in order to bill for this code.

REGULATORY REFERENCES

CMS Claims Processing Manual 100-04, Ch. 12, 30.6.9.1 – Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Services), 30.6.9.2 – Subsequent Hospital Visit and Hospital Discharge Day Management (Codes 99231 – 99239), 30.6.10 – Consultation Services

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Centers for Medicare and Medicaid (CMS)

QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.