1. From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing:Coding Inpatient Professional Services Date:21 March 2007 Time:0900 - 0950

2. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives Rounds defined Be aware of E&M coding issues Be aware consults in the inpatient setting have different rules Special services defined Be aware of diagnosis coding Be aware of procedure coding issues

3. 2007 UBO/UBU Conference From Registration to Accounts Receivable 3 Professional Component The MHS captures inpatient workload with professional and institutional data. All SADRs generated have a flag that indicates if the patient is inpatient or outpatient – Inpatient rounds are captured in the A MEPRS Internal Medicine AAAA Family Practice AGAA Obstetrics ACCA – An appointment type in DoD information systems (CHCS/AHLTA/P-GUI) is designed to capture professional services delivered in the inpatient environment by the service of the attending provider of record Attending Service – The medical or surgical service to which the patient is officially admitted via admission or transfer orders

4. 2007 UBO/UBU Conference From Registration to Accounts Receivable 4 Institutional Service Inpatient services provided by certain personnel are considered institutional service/cost and will not produce an inpatient professional service round – Radiology – Laboratory – Pharmacy – Anesthesiology These staff members may be included as secondary providers on an ADM encounter involving a privileged provider (e.g., the attending would be the primary provider and a resident would be the secondary provider) – House staff – Technicians – Physician extenders – Non-privileged providers

5. 2007 UBO/UBU Conference From Registration to Accounts Receivable 5 Generation of Rounds Patient presents to family practice clinic encounter – FP identifies Abdominal Pain Fever – FP proceeds with admission Attending physician is FP

6. 2007 UBO/UBU Conference From Registration to Accounts Receivable 6 Admission Service 3 key components – DOCUMENTED – 99221 Detailed – history Detailed – exam Low med decision making – 99222 Comprehensive – history Comprehensive – exam Moderate med decision making – 99223 Comprehensive – history Comprehensive – exam High-med decision making

7. 2007 UBO/UBU Conference From Registration to Accounts Receivable 7 Rounds Generation Rounds are generated by two methods – Automatically At census hour to the admitting service A MEPRS – Attending provider field must be filled in Per MHS policy, house staff do not have admitting privileges. If a house staff officer receives an inpatient RNDS, the record needs to be redirected to the attending provider – Manual Creation Why would you do this? – Interservice transfers – Transfer precipitated by the consult

8. 2007 UBO/UBU Conference From Registration to Accounts Receivable 8 Subsequent Hospital Care 2 of 3 Key Component DOCUMENTED – 99231 Problem-focused INTERVAL history Problem-focused exam Low med decision making – 99232 Expanded problem-focused INTERVAL history Expanded problem-focused exam Moderate med decision making – 99233 Detailed INTERVAL history Detailed exam High med decision making

9. 2007 UBO/UBU Conference From Registration to Accounts Receivable 9 Discharge Services Hospital Discharge Services – The hospital discharge day management codes are to be used to report the total duration of time spent by the physician for final hospital discharge of a patient – The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms 99238 – 30 minutes or fewer 99239 – more than 30 minutes

10. 2007 UBO/UBU Conference From Registration to Accounts Receivable 10 Admit/Discharge Same Day The following codes are used to report observation or inpatient hospital care provided to patients admitted and discharged on the same date of service – 3 Key Components DOCUMENTED 99234 – Detailed or comprehensive history – Detailed or comprehensive exam – Straightforward or low med decision making 99235 – Comprehensive history – Comprehensive exam – Moderate med decision making 99236 – Comprehensive history – Comprehensive exam – High med decision making

11. 2007 UBO/UBU Conference From Registration to Accounts Receivable 11 Observation Status This is an outpatient status – Patients may not be discharged from inpatient status to observation status These codes are for direct admit to observation status Patients may go from observation to admit status – 3 Key Components DOCUMENTED 99218 – Detailed or comprehensive history – Detailed or comprehensive exam – Straightforward or low med decision making 99219 – Comprehensive history – Comprehensive exam – Moderate med decision making 99220 – Comprehensive history – Comprehensive exam – High med decision making

12. 2007 UBO/UBU Conference From Registration to Accounts Receivable 12 Observation Care Discharge Services Observation care discharge of a patient from “observation status” includes final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records – 99217

13. 2007 UBO/UBU Conference From Registration to Accounts Receivable 13 Inpatient Consults Inpatient Consult – A consult resulting from a request by the attending physician to evaluate or give advice – It may initiate diagnostic or therapeutic services to an inpatient remaining under the care of the attending physician There is only one inpatient consult code per service per admission Follow-up inpatient consults from that service are coded with subsequent E&M hospital day codes – There must be a written request in the inpatient record, and a written consult in the inpatient record

14. 2007 UBO/UBU Conference From Registration to Accounts Receivable 14 Inpatient Consult Codes 3 Key Components DOCUMENTED – 99251 Problem focused history Problem focused exam Straightforward med decision making – 99252 Expanded problem focused history Expanded problem focused exam Straightforward med decision making – 99253 Detailed history Detailed exam Low med decision making – 99254 Comprehensive history Comprehensive exam Moderate med decision making – 99255 Comprehensive history Comprehensive exam High med decision making

15. 2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Critical Care Determined by condition, not location – I.e., patient location may be intensive care unit Critical care is the direct delivery by a physician of medical care for a critically ill or critically injured patient Critical care involves high complexity decision making to assess, manipulate, and support vital system functions – 99291 - First 30 – 74 minutes; “stable” is not sufficient documentation to explain 30+ minutes of service – 99292 – Each additional 30 minutes Do NOT use for concurrent care

16. 2007 UBO/UBU Conference From Registration to Accounts Receivable 16 Diagnosis Coding First and subsequent days – code what is addressed during that episode of care (usually rounds are for the entire day, it could be multiple rounds but one code) known at that time Only code abnormal labs/rads when DOCUMENTED by the provider in the doctor’s note – Rationale Just like outpatient professional, you code what you know at the encounter Do not code “rule out,” “suspect,” or any other “questionable” diagnosis When doing data analysis, the diagnoses associated with the 99221/9922/99223 initial hospital care and 99231/99232/99233 subsequent hospital care will sometimes be symptoms and will frequently be follow up to surgical procedure or fracture aftercare (for example, V54.14 aftercare for healing traumatic fracture of hip) Collect the progression of the workup and treatments leading to final (principal) diagnoses

17. 2007 UBO/UBU Conference From Registration to Accounts Receivable 17 Example 1 Medicine with or without complications Admit – Code why (e.g., chest pain) – Do not code the “rule out MI” for the E&M, it is based on the documentation for an initial hospital care – Code the sign and symptom chest pain Subsequent – Code what was known at time of documentation (e.g., MI) for the E&M – It is based on the documentation for a subsequent hospital care Discharge – Code principal diagnosis (e.g., MI) for the E&M, it is based on the documented time

18. 2007 UBO/UBU Conference From Registration to Accounts Receivable 18 Example 2 Planned surgical admission Admission – Code menorrhagia – Hysterectomy (CPT based on documentation) – E&M would be 99499 Subsequent – Code aftercare ICD – 99024 Global – E&M 99499 Discharge – Code principal diagnosis (uterine fibroids) – 99024 Global – E&M of 99499

19. 2007 UBO/UBU Conference From Registration to Accounts Receivable 19 Surgical Complication A complication is an UNEXPECTED issue, that “complicates” normal care for that postoperative time A fever and pain frequently accompany post operative care as do some “what-could-be-abnormal” laboratory values Only code something as a complication if the provider specifically documents it as a complication

20. 2007 UBO/UBU Conference From Registration to Accounts Receivable 20 Example 3 Planned surgical admission with complication Admission – Code menorrhagia – Hysterectomy (CPT based on documentation) – E&M would be 99499 Subsequent – Code aftercare – 99024 Global – E&M 99499 Subsequent – Documented “complication,” sequence the complication first, then the aftercare V-diagnosis – Use subsequent hospital care codes 99231-99233 Discharge – Code principal diagnosis (uterine fibroids) and complications – 99024 Global – E&M of 99499

21. 2007 UBO/UBU Conference From Registration to Accounts Receivable 21 Example 4 Medicine admission with unplanned global surgical event Admit – Code why (e.g., abdominal pain) – E&M based on the documentation for an initial hospital care 99221- 99223 Subsequent – – Code what was known (e.g., abdominal pain) – E&M based on the documentation for subsequent hospital care 99231-99233 Operative day – Code the postoperative diagnosis – Code the CPT surgical procedure (appendectomy) Subsequent – Code aftercare ICD – Code 99024 if no postoperative complications – E&M 99499 Discharge – Code principal diagnosis appendicitis – Code 99024 – E&M of 99499

22. 2007 UBO/UBU Conference From Registration to Accounts Receivable 22 Diagnosis Coding Discharge day – Code everything that was addressed during the hospitalization, with the principal diagnosis being the first listed SADR diagnosis – Rationale When doing data analysis, the diagnoses associated with the 99238/39 discharge hospital care and admit/discharge same day (99234-99236) will feed to the bill

23. 2007 UBO/UBU Conference From Registration to Accounts Receivable 23 MEPRS THOU SHALL NOT collect inpatient professional services in the B*** MEPRS, except for initial consults A consult stops being a consult and becomes subsequent hospital care when a definitive diagnosis is made or when the provider assumes responsibility for that medical issue

24. 2007 UBO/UBU Conference From Registration to Accounts Receivable 24 Summary Rounds – We know what they are E&M coding issues – Some are 2 of 3 key components – Some are 3 of 3 key components Be aware consults in the inpatient setting have different rules – Only one consult Special services defined Diagnosis coding – Signs and symptoms vs confirmed Be aware of procedure coding issues – Coded as part of inpatient stay