procedure code and description

99222 – Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided 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. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit. – average fee amount – $130 – $140

So with that in mind, let’s take a systematic look at the hospital admission The codes 99222 and 99223 are what I will cover, because 99221 should probably not be admitted to the hospital.

Unless of course you have failed outpatient management with them.


99222 requires:

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

1. A Comprehensive History (See Here)
2. A Comprehensive Examination (See Here)
3. Medical Decision Making of Moderate Complexity

Comprehensive History:

• Chief complaint/reason for admission
• Extended history of present illness (HPI)
– Extended consists of four or more elements of the HPI
• Review of systems directly related to the problem(s) identified in the history of present illness
• Medically necessary review of ALL body systems’ history
• Medically necessary complete past, family and social history
• Four or more elements of the HPI or the status of at least three (3) chronic or inactive
conditions, noting that medical necessity is ALWAYS the overarching criterion.

Procedure Code 99223

Medicare allows only the medically necessary portion of a face-to-face visit. Even if a complete note is generated, only the necessary services for the condition of the patient at the time of the visit can be considered in determining the level/medical necessity of any service.

Initial Hospital Care:

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

• Comprehensive history
• Comprehensive exam
•  Medical Decision making of HIGH complexity

Comprehensive History:

• Chief complaint/reason for admission
• Extended history of present illness (HPI)
—
Extended consists of four or more elements of the HPI

• Review of systems directly related to the problem(s) identified in the history of present illness
• Medically necessary review of ALL body systems’ history
• Medically necessary complete past, family and social history
•  Four or more elements of the HPI or the status of at least three (3) chronic or inactive conditions, noting that medical necessity is ALWAYS the overarching criterion.


HPI – History of Present Illness:

A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include:

• Location
• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs/symptoms significantly related to the presenting problem(s)

Chief Complaint:

The Chief Complaint is a concise statement from the patient describing:

• The symptom
• Problem
• Condition
• Diagnosis
• Physician recommended return, or other factor that is the reason for the encounter




Billing and Coding Guidelines

According to Current Procedure terminology (procedure ®) instructions, Initial Hospital Care codes 99221, 99222 and 99223 are used to report the first hospital inpatient encounter of a new or established patient by the admitting physician. These codes are used per day and require three key components: detailed/comprehensive history, detailed/comprehensive examination and medical decision making of low, medium or high complexity. For initial inpatient encounters by physicians other than the admitting physician, initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231- 99233) as appropriate should be reported. Only one initial hospital care service is payable per patient per hospital stay.

Initial Hospital Care, per day, for the evaluation and management of a patient, which requires these 3 components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity.


CMS Definitive: An edit sourced to a specific billing guideline from CMS. For example the Medicare Claims Processing Manual states “If the same physician who admitted a patient to observation status also admits the patient to inpatient status from observation before the end of the date on which the patient was admitted to observation, pay only an initial hospital visit for the evaluation and management services provided on that date.” UnitedHealthcare Community Plan will not separately reimburse for an initial observation care service on the same date as an initial hospital care service, such as 99218 and 99222


Consultation code as Initial visit

Policy: Effective January 1, 2010, procedure  consultation codes were no longer recognized for Medicare Part B payment. As explained in CR 6740, Transmittal 1875, Revisions to Consultation Services Payment Policy, issued on December 14, 2009, physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. CMS instructed providers billing under the PFS to use other applicable E/M codes to report the services that could be described by procedure  consultation codes. CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians where permitted) who perform an initial E/M service may bill the initial hospital care codes (99221 – 99223).

CMS is aware of concerns pertaining to reporting initial hospital care codes for services that previously could have been reported with procedure  consultation codes and for which the minimum key component work and/or medical necessity requirements for procedure  codes 99221 through 99223 are not documented. Providers may report procedure  code 99221 for an E/M service if the requirements for billing that code, which are greater than procedure  consultation codes 99251 and 99252, are met by the service furnished to the patient.

In situations where the minimum key component work and/or medical necessity requirements for initial  hospital care services are not met, subsequent hospital care procedure  codes (99231 and 99232) could potentially meet requirements to be reported for an E/M service that could be described by procedure  consultation code 99251 or 99252. Contractors shall expect changes to physician billing practices accordingly. Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases 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.