Authors: John Malaty, Lisa Gilbert, Kimberly Legere-Sharples, Kay Kelts, Elizabeth Close, Wendy Shen
Many family physicians provide inpatient medicine coverage to patients of all ages. For inpatient admissions and established follow-up care, most coding is based on Medical Decision-Making, (MDM) although time-based coding can be used.
Inpatient services billed based on medical decision-making utilize a single CPT billing code for all services provided during each day, no matter how much additional time is spent beyond the initial rounding. Time-based billing is more commonly used in critical care, since this can involve multiple patient care interventions throughout the day.
Admission and Subsequent Inpatient Care
Medical decision-making is based on specified criteria from your assessment and plan, including the number and complexity of medical problems, the amount of data reviewed, and the medical risk or severity of conditions and interventions. The same criteria are used for inpatient admissions and subsequent inpatient care. You only need to document medically-pertinent portions of the history and physical exam. While they still should be included in your documentation, as of January 1, 2023, there are no other specific documentation requirements for history and physical exam. This has made inpatient documentation much easier, allowing physicians to focus on documenting only what is medically necessary.
Additionally, prior to January 1, 2023, there were both observation and inpatient CPT billing codes, but this was simplified into one set of codes for all inpatient billing (i.e., there are no longer separate observation CPT billing codes). Patients are still placed 
in the hospital as “observation” or “admission” for hospital billing, but not for your billing.
Pro-Tip: After reviewing outpatient billing and coding, just focus on the small differences in inpatient billing and coding and it will be easier to master! Both outpatient and inpatient MDM criteria require that you satisfy MDM criteria in two out of the three categories. Again, these three categories are the number and complexity of medical problems, the amount of data reviewed, and the medical risk or severity of conditions and interventions.
There are 3 billing levels for regular inpatient services, both for admissions and for subsequent visits (daily rounds), often referred to as Level 1, 2 and 3. (Infant and Pediatric ICU care and time-based critical care use different codes).
Inpatient admission codes and/or inpatient subsequent visit codes are as follows:
Level 1 services: Admission 99221 (>40 minutes)/Subsequent 99231 (>25 minutes) - Low MDM*
a) This level 1 inpatient visit (with low MDM) is equivalent to MDM for outpatient level 3 visits (99203/99213)
i) One additional inpatient criterion for level 1 services is “1 acute uncomplicated illness/injury requiring hospital inpatient/observation level of care.”
Level 2 services: Admission 99222 (>55 minutes)/Subsequent 99232 (>35 minutes) - Moderate MDM*
b) This level 2 inpatient visit (with moderate MDM) is equivalent to MDM for outpatient level 4 visits (99204/99214)
Level 3 services: Admission 99223 (>75 minutes)/Subsequent 99233 (>50 minutes) - High MDM*
c) Level 3 inpatient visits (with high MDM) is equivalent to MDM for outpatient level 5 visits (99205/99215)
i) One additional inpatient criterion for level 3 services is “parenteral controlled services.”
*The last bolded digit indicates that it is a billing level 1, 2 or 3 service.
*The 2nd to last underlined digit indicates if it is an admission/initial service (2) vs. subsequent service (3).
When billing by time for admission services, this time can be counted continuously, even if it extends past midnight into the following day. This is a distinction from billing by time in the outpatient setting, where it must be on the same day the patient is seen in the clinic. However, this makes perfect sense since a patient may start admission before midnight, but they are still being admitted past midnight—it is still the total continuous time for that same admission.
Discharge
Choose one of two codes based on the time spent on discharge. This code is appropriate for discharges of patients of all ages.
99238: Discharge taking < 30 min**
99239: Discharge taking > 30 min**
**The 2nd to last underlined digit indicates that this is a subsequent service (3) after admission.
Pro-Tip: Discharge coding is based on Attending time (not nursing time, medical student time, resident time, or case-management time). As an attending, you should enter a statement attesting to the amount of time spent on discharge on the day of discharge, which includes seeing the patient, counseling, the note, and care coordination, especially if billing for a 99239 (time attestation isn’t needed for 99238).
Admission and Discharge on the Same Day
There are billing codes that take into account admission and discharge on the same day (since there is more to evaluate and manage); use these when applicable:
Level 1 services: 99234 (>45 minutes) - low MDM**
Level 2 services: 99235 (>70 minutes) - moderate MDM**
Level 3 services: 99236 (>85 minutes) - high MDM**
*The last bolded digit for admission and discharge on the same day “picks up” where the prior admission CPT codes “left off” and follow in order (last digit for admission CPT codes left off on 3 and these CPT codes for admission and discharge on the same day end with 4 through 6).
**The 2nd to last underlined digit of the above CPT codes still indicates if it is a subsequent service (3) since this CPT code includes the discharge CPT codes.
Initial Consultation:
|
CPT Code
|
Medical Decision Making
|
Total Time (min)*
|
|
99252
|
Straightforward
|
35
|
|
99253
|
Low
|
45
|
|
99254
|
Moderate
|
60
|
|
99255
|
High
|
80
|
*Total time on the day of service is used (not only face-to-face time)
Documentation:
Besides documenting what is medically necessary, you must document who requested the consultation and address their clinical question(s). You must also ensure the requesting physician/service receives a copy of the consultation (or is using the same electronic medical record system where it is easily accessible).
Subsequent Consultation Services:
Only one initial consultation can be reported by a consultant per admission. Subsequent consultation services (rounding) during the same admission are reported using subsequent care inpatient codes (99231-99233). See “Admission and Subsequent Inpatient Care” coding section for more detail.
While Initial Consultation codes are important to understand, since they can reimburse well and private insurance companies still may pay them, other payers may not reimburse consultation codes. Please check with your institution regarding coverage for hospital consultations. Since 2010, Medicare hasn’t paid for consultation codes. For Medicare and any insurance company that doesn't reimburse for consultation codes, use the following “walk-over” of the consultation codes to the initial inpatient care codes (admission codes).
|
MDM of the Consult
|
Insurance Covers Consultation Codes
Use Consultation CPT Codes
|
Insurance Doesn’t Cover Consultation Codes,
i.e., Medicare Use Initial Inpatient CPT Codes
|
|
Straightforward
|
99252
|
-
|
|
Low
|
99253
|
-
|
|
Moderate
|
99254
|
99222
|
|
High
|
99255
|
99223
|
This arrangement makes sense when you look at the required medical decision-making (similar MDM for the same consultation CPT codes and initial inpatient CPT codes).
Consultations are an important part of hospital-based practice. Family Physicians have a broad scope of training and a unique perspective in medicine that make us important consultants. While initial consultation reimburses well, it is important to know how to document them and who will pay for them. Like anything, the more you do it, the easier it gets!
Critical Care Services (all ages) - Definition:
Code Blue and/or Time-Based Intensive Care
● Time is total, aggregate time spent on one date, even if time is non-contiguous. One exception: If it extends past midnight, can only count time spent continuously that extends past midnight
● Time doesn't need to be face-to-face
● Can be billed as split/shared services by more than 1 practitioner, based on cumulative time spent/documented on the same day
What constitutes intensive care?
● Clinical decisions addressing organ system failure or the prevention of further life-threatening deterioration
● Highly complex clinic decisions based on interpretation of complex data and/or use of advanced technology
● Both the clinical status of the patient and the care rendered by the provider are critical in nature
● All reasonable sites of service are permissible when the clinical condition meets the critical care definition (intensity of care and time spent), i.e., this coding may occur in an intermediate care unit in a decompensating patient.
You would include time spend in the performance and/or interpretation of labs, diagnostic studies, and procedures inherent to the critical care and not bill them separately, for instance:
● Interpretation of cardiac output measurement
● Interpretation of chest X-rays
● Interpretation of blood gas
● Gastric intubation
● Temporary transcutaneous pacing
● Ventilator management
● Vascular access procedures
Critical Care in Adults:
Critical care: 30-74 minutes: CPT 99291
Critical care: each additional 30 minutes; 1st increment would be >104 minutes (74 minutes + 30 minutes): CPT 99292
● 2023 guidelines clarified that you must provide an entire additional 30 minutes to bill 99292
Use the -25 modifier for a separately identifiable service, besides those listed above, such as a lumbar puncture or a central line placement, when performed on the same day as critical care services (usually with a 10-day global period or less). However, you should make it clear in your documentation that this wasn’t included in your critical care time, i.e., “The time needed to perform subclavian central line insertion wasn’t included in total critical care time reported.”
Use the -57 modifier for a decision to send a patient to surgery, usually for procedures that have a 90-day global period.
Critical Care in Children:
Critical care definitions are similar in adults and children, but different codes are used depending on the age of the child. Unlike time-based codes, these are per-day codes. If a child has coded, time-based coding would be appropriate.
Neonates <28 days admitted to the NICU:
● 99468 for initial admission
● 99469 for each subsequent day
● 99238 or 99239 for discharge (same as adult)
● Exception: When a low birth weight newborn is hospitalized in the NICU expressly for gaining weight but without critical care needs, then use the following codes for each day based on daily weight at the time of service:
● <1500 grams: 99478
● 1500-2500 grams: 99479
● 2501-5000 grams: 99480
Children age 29 days to 24 months admitted to PICU:
● 99471 for the entire first day of initial critical care
● 99472 for each subsequent inpatient critical care day
● 99238 or 99239 for discharge (same as adult)
Children age 2-5 years old in PICU:
● 99475 for the entire first day of initial critical care
● 99476 for each subsequent inpatient critical care day
● 99238 or 99239 for discharge (same as adult)
Newborn procedures for vascular access and stabilization might be performed, but most will be included in the codes for critical care (see below list). If billed separately, they will be eliminated. If other procedures not listed below are performed, such as lumbar puncture (62270), which should be billed separately with a 25 modifier.
● Interpretation of cardiac output measurement
● Chest X-rays
● Monitoring or interpretation of blood gas or oxygen saturation
● Gastric intubation
● Temporary transcutaneous pacing
● Ventilator management
● Vascular access procedures
● Umbilical venous and umbilical arterial catheters
● Other arterial catheters, and central or peripheral vessel catheterization
● Vascular access procedures and vascular punctures
● Endotracheal intubation and lumbar puncture
● Bladder aspiration and bladder catheterization
● CPAP and surfactant administration
● Transfusion of blood products
● Bedside pulmonary functioning test
Newborn Care Services
There are only a few hospital codes for routine newborn care. The Admission History and Physical (H&P) should be completed within 24 hours of birth and requires documentation of the mode of delivery, any complications, prenatal concerns or maternal risk factors, and a full physical exam. It should be billed on the day the exam was completed, which may be the subsequent calendar day after delivery.
There is only one code for subsequent hospital care (newborn rounding), and two possible codes for discharge, based on time spent with the family and care coordination. The majority of newborn discharges will take less than 30 minutes. Finally, there will be occasions where a newborn has the H&P and discharge completed on the same calendar day. For example, an infant born at 8 pm may have an H&P performed after midnight, and the infant might be discharged that evening after 24 hours. This would be billed as a Same-Day Admission and Discharge.
● Newborn Admission (History and Physical): 99460
● Newborn Subsequent Visit: 99462
● Newborn Same Day Admission and Discharge: 99463
● Newborn Discharge: 99238 (<30 minutes) and 99239 (>30 minutes)
Circumcisions and common newborn procedures.
● Newborn Circumcision (any method) with dorsal block: 54150
● Newborn Frenulum incision (tongue-tie release): 41010
● Newborn polydactyly or skin tag suture ligation (up to 15): 11200
If a newborn is discharged home and subsequently readmitted, but not requiring intensive care (even if the patient happens to be in the NICU for logistical or infectious reasons), regular inpatient care codes are used, similarly to adult inpatient coding (Admission 99221-99223 and Subsequent 99231-99233). Examples may include admission for jaundice or dehydration.
Emergency Department Coding and Billing
Similar to inpatient coding, emergency department coding is determined based on MDM, and there are five Levels, although the lowest doesn’t require the presence of a physician (e.g., dressing change, suture removal). Also, the documentation requirements have been removed for history and physical exam, but medically necessary information should still be documented, along with justification for MDM. Two of the three categories (the number and complexity of medical problems, the amount of data reviewed, and the medical risk or severity of conditions and interventions) must be met to reach the level of MDM.
● Level 1: 99281 - “Nursing” visit
● Level 2: 99282 - Straightforward
● Level 3: 99283 - Low Complexity
● Level 4: 99284 - Moderate Complexity
● Level 5: 99285 - High Complexity
Many stabilizing interventions are included in the codes above, such as intubation and ventilator management, transcutaneous pacing, etc. For critical patients, time-based critical care codes can be used instead.
Skilled Nursing Facility/Nursing Facility Coding and Billing
Skilled Nursing Facility (SNF) and Nursing Facility (NF) care are excellent opportunities for family physicians to provide continuous care for our patients. Medical directorship of a SNF or NF can provide additional income. Many elements of SNF/NF visits will look very similar to inpatient and outpatient codes/requirements, with some exceptions noted below.
NOTE: Both independent and assisted living visits are billed as a home visit (see Outpatient Billing and Coding).
The initial SNF visit must be performed by a physician within 30 days of admission, performing a comprehensive assessment, developing a plan of care, and verifying admission orders. Medicare will pay for a hospital discharge and a nursing home admission on the same day. Medicare mandates that patients be seen every 30 days for the first 90 days of their stay and every 60 days thereafter. These visits are considered timely if they are performed within 7 to 10 days of the date the visit was requested (state laws may vary). After the initial physician visit in the SNF, alternating federally mandated visits may be performed by a non-physician provider (NPP), such as an APRN or PA, even if they are employed by the SNF.
Acute illness/injury-related visits may be performed by a physician or NPP any time as long as medically necessary. These can be performed before the initial visit or between mandated visits. State laws vary in regard to ability to do initial visits under physician supervision in non-skilled nursing facilities, as long as the NPP isn’t employed by the facility.
SNF and NF billing codes are based on MDM or on time. As of January 1, 2023, there are no longer specific documentation requirements for history and physical exam, other than needing to document what is medically necessary. In addition, the CPT code for nursing home annual exams (99318) was eliminated and should be coded similarly to a subsequent nursing home visit.
NOTE: Consultation codes may not be billed in the SNF/NF setting, although prolonged service codes are allowed.
There are 3 billing levels for initial nursing home services (similar to inpatient services) and 4 billing levels for subsequent nursing home services. The following format is used:
Nursing home initial visit CPT code (minimum time for that initial visit when billing by time)/Nursing home subsequent visit CPT code (minimum time for that subsequent care when billing by time):
Level 1 services: Initial visit 99304 (>25 minutes)/Subsequent 99308 (>15 minutes) = low MDM*
a) This level 1 nursing home visit (with low MDM) is equivalent to MDM for level 1 inpatient visits (99221/99231) and outpatient level 3 visits (99203/99213)
i) There is also an additional CPT code for subsequent visits only (not for initial visits) that is for straightforward MDM (MDM is equivalent to level 2 outpatient visits 99202/99212) - CPT 99307 (10-14 minutes).
Level 2 services: Initial visit 99305 (>35 minutes)/Subsequent 99309 (>30 minutes) = moderate MDM*
b) This level 2 nursing home visit (with moderate MDM) is equivalent to MDM for inpatient visits (99222/99232) and outpatient level 4 visits (99204/99214)
Level 3 services: Initial visit 99306 (>45 minutes)/Subsequent 99310 (>45 minutes) = high MDM*
c) Level 3 inpatient visits (with high MDM) is equivalent to MDM for inpatient visits (99223/99233) and outpatient level 5 visits (99205/99215)
*All the nursing home visits start with “9930_” and the last digit defines whether it is an initial visit vs. subsequent visit, in addition to which level visit it is.
Discharge CPT codes are 99315 and 99316, depending on < 30 minutes vs > 30 minutes spent on the discharge visit, respectively.
NOTE: Time-based billing in the SNF/NF setting is based on total floor time to include chart review, communication with other healthcare team members, writing the note, etc., rather than just face-to-face time. The discharge note/billing should be dated according to the day of the face-to-face visit even if the patient is discharged on a different calendar day. If the patient dies, these codes can only be used if the physician or APP personally performed the death pronouncement.
Other services you may provide to your patient in this setting are Medicare Annual Wellness Visit (AWV) and Advanced Care Planning (ACP). See the Annual Wellness section for more about AWV and ACP coding.
Global Obstetric (OB) Codes
The maternal OB package (OB Global billing) allows providers to bill for a single CPT code for all outpatient prenatal care, labor and delivery, and subsequent inpatient and outpatient postpartum services. This is called “bundling” and is sometimes used in other procedures where the services and time-frames are very well defined. The code is determined by the route of delivery.
These maternal OB package codes cover all obstetric care from the first prenatal visit through the 6-8 week postpartum visit. A physician should bill them as a one-time procedure after delivery. However, the maternal OB package doesn’t cover all services that a physician might provide while the patient is pregnant. The billing code only covers 13-15 antepartum visits, the delivery itself, and one postpartum visit. Visits for issues unrelated to pregnancy would be coded separately. If it is a high-risk pregnancy or there are complications related to pregnancy, such as a third or fourth degree laceration repair, they aren’t treated as routine and should be billed separately.
The delivery portion covers admission to the labor and delivery floor, comprehensive management of labor including fetal monitoring, rupture of membranes, induction or augmentation of labor, delivery, including forceps or vacuum, episiotomy, 1st and 2nd degree laceration repair, uncomplicated postpartum inpatient care (48 hours for vaginal delivery, 72 hours for C-section) and discharge.
Maternal OB package codes:
|
CPT
|
|
|
59400
|
Vaginal delivery
|
|
59510
|
C-section delivery
|
|
59610
|
Vaginal delivery after C-section (VBAC)
|
|
59618
|
C-section delivery after “failed” TOLAC
|
The outpatient visits are only for the physician’s services. All other services, such as NST, BPP, labs, swabs, and ultrasound, should be charged separately.
Any triage on the Labor/Delivery unit during the pregnancy, such as “rule-out” of labor or spontaneous rupture of membranes (SROM), and any admission during the postpartum period, such as for endometritis or postpartum preeclampsia, should also be charged separately. The most likely missed codes are for antepartum triage and related admissions. Observation codes were removed on Jan 1, 2023 and regular inpatient admission CPT codes and discharge CPT codes should be used, but these must occur greater than 1 day prior to delivery and not immediately precede delivery See the inpatient coding section for more detail, especially as you work through the following case:
Case: You have been seeing a patient throughout her prenatal care. She was admitted at 33 weeks gestational age with preterm labor, in the setting of prior incompetent cervix (CPT 99222 for this high-risk pregnancy admission). After 2 days of hospitalization (CPT 99232 billed for each of those 2 rounding days), her membranes rupture and the following morning (within 24 hours of her membranes rupturing) she delivers a healthy male, vaginally, without complications. Inpatient and outpatient postpartum course is uneventful (CPT 59400 billed for maternal OB package as listed above).
Partial OB Services Billing
If the services provided don't meet the requirements for the global obstetric package code (where all services, including delivery, are provided by the same physician group practice/midwife, under the same tax ID), then you need to bill using standalone billing codes. These may include individual evaluation and management codes, antepartum care only, delivery only, postpartum care only, etc.
NOTE: Both vaginal deliveries and C-section codes include postpartum rounds and discharge.
|
CPT
|
Description
|
|
Routine outpatient CPT for E/M
|
Antepartum care only: 1-3 visits
|
|
59425
|
Antepartum care only: 4-6 visits
|
|
59426
|
Antepartum care only: > 7 visits
|
|
59430
|
Outpatient postpartum care only
|
|
59409
|
Vaginal delivery only
|
|
59410
|
Vaginal delivery and outpatient postpartum care
|
|
59612
|
Vaginal delivery only, after prior C-section (VBAC)
|
|
59614
|
Vaginal delivery, after prior C-section delivery (VBAC), and outpatient postpartum care
|
|
59514
|
C-section delivery only
|
|
59515
|
C-section delivery and outpatient postpartum care
|
|
59620
|
C-section delivery only, following attempted vaginal delivery (TOLAC), after prior C-section delivery
|
|
59622
|
C-section delivery, following attempted vaginal delivery (TOLAC), after prior C-section delivery and outpatient postpartum care
|
Summary
● OB Global billing code covers 13 to 15 routine antepartum office visits, labor and delivery management, routine postpartum hospital care, and 1 routine postpartum office visit.
● If the complete bundle of services aren’t provided, there are “piece-meal” codes for both outpatient and inpatient obstetrical services.
● Other services during antepartum office visits (e.g., NST and ultrasound) and antepartum hospitalizations for high-risk pregnancy or pregnancy-related complications are separately billable services, based on time and complexity and should be reported in addition to global OB billing.
● Complicated postpartum (e.g., elevated blood pressure) care can also be billed separately.