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EVALUATION AND MANAGEMENT (E/M)
CODING AND DOCUMENTATION
FOR
NEUROLOGY HOSPITAL
ADMISSIONS |
Coding and documentation for neurology
admissions to the hospital are similar to that for
outpatients. Note some of the major differences when
using these
codes:
●
there are only 3 levels for the day of admission
service
●
there are only 3 levels for subsequent day of
service
●
there are separate codes for the day of discharge
●
time spent is not only face to face time with the patient,
but also includes time spent on the floor/unit rendering services
for patient (e.g., reviewing the chart, writing notes,
talking to other doctors, talking to the family, etc.)
The
most recent E/M coding and documentation rules are
found in the
1997 Documentation Guidelines for
Evaluation and Management Services, from
the Center for Medicare & Medicaid Services (CMS). A
simplified approach, tailored for neurology follows
below, based first on determining the level of Medical
Decision Making. |
The documentation of all E/M codes involves (3)
components:
•
History
•
Examination
•
Medical Decision Making
Among these three components, it
is the Medical Decision Making (MDM) that is most patient specific. The MDM in essence drives
which E/M code to use. Among other factors, it
incorporates the severity of the illness, the complexity
of the case, review of outside records, and undertaking
diagnostic testing and treatment. Thus,
one of the best
approaches to E/M coding is to first determine the level
of MDM (click
here to learn how to determine the level of MDM). Once that is determined, the proper E/M code is
determined depending if the service is for the day of
admission or subsequent follow-up care in the hospital. Then it is
straightforward of to determine how much and what detail of History
and Physical Examination must be documented. |
Selection of
the Proper E/M Code and Documentation of the Required
History and Examination
Once the level of MDM is determined, the
correct E/M code is selected depending on whether the
visit is for the day of admission, subsequent daily
care, or the day of discharge.
Once the code is selected, then there is specific
history and exam documentation required for that code (click
on each code below to review the specific documentation
requirements). |
Hospital Inpatient Services E/M Codes for
Neurology
Level of MDM |
Initial Hospital Care |
Subsequent
Daily Care |
Straightforward
or
LowComplexity |
99221 |
99231 |
Moderate Complexity
|
99222 |
99232 |
High Complexity
|
99223 |
99233 |
|
Discharge Care
Time Spent |
Discharge Care |
< 30 minutes |
99238 |
> 30 minutes |
99239 |
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Alternative E/M Coding:
Using Time
If you document the total time and note that counseling
and coordinating care required more than 50% of the
encounter, then time may be used to determine the level
of service. Documentation may refer to:
•
diagnostic results, impressions and plans for other
studies
•
prognosis
•
differential diagnosis
•
risks, benefits of treatment
•
instructions
•
compliance
•
risk reduction
•
patient and family education
As opposed to outpatients where
the total time is only face to face time with the patient,
time for hospitalized patients
also includes any time spent on the floor/unit rendering services
for patient (e.g., reviewing the chart, writing notes,
talking to other doctors, talking to the family, etc). The average total times
for
the E/M hospital admission codes and average Medicare
reimbursement are listed below.
Initial
Hospital
Care |
Hospital
Subsequent Care |
Day of
Discharge |
Low 99221
($84) |
30 minutes |
Low 99231($34) |
15 minutes |
99238($64)
|
< 30 minutes |
Mod 99222($115) |
50 minutes |
Mod 99232($62) |
25 minutes |
99239($91) |
> 30 minutes |
High 9923
($169) |
70 minutes |
High 99233($89) |
35 minutes |
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Condensed E/M Coding for
Hospital Inpatient Services for Neurology
Sheet (pdf):
Two page file that can be printed for quick reference in
the office setting (Download here)
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Legal disclaimer:
the above information regarding hospital admission E/M codes is
deemed reliable. However, physicians should always
confirm the information in the
1997 CMS
guidelines. |
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