Billing/Coding

Billing Codes – Below are 2 approaches to coding and an inpatient billing encounter form.

First approach

Observation (single day visit)

99221
detailed hx
detailed exam
straightforward complexity

99222
comprehensive hx
comprehensive exam
moderate complexity

99223
comprehensive hx
comprehensive exam
high complexity

Observation (Seen on different dates)
99217 – Observation care discharge (Medicaid doesn’t recognize)
99218 – Detailed/Straightforward
99219 – Comprehensive/Mod Complexity
99220 – Comprehensive/High Complexity

Follow up care
99231 – Problem focused/Straightforward
99232 – Expanded/Mod Complexity
99233 – Detailed/High Complexity

Initial visit
99221 – Detailed/Straightforward
99222 – Comprehensive/Mod Complexity
99223 – Comprehensive/High Complexity

Initial consult
99251 – Prob. Focused/Straightforward
99252 – Expanded/Straightforward
99253 – Detailed/Low complexity
99254 – Comprehensive/Mod. Complexity
99255 – Comprehensive/High Complexity

Dialysis

90935 single HD visit
90937 repeated HD visit
90945 single PD visit
90947 repeated PD visit

Other

92950 CPR
96800 HD cannula
36620 Arterial line

I. Hx

Problem focused
HPI 1 element
ROS none
PAST none

Expanded problem focused
HPI 1 element
ROS 1 element
PAST none

Detailed
HPI 4 elements or 3 chronic conditions
ROS 2 elements
PAST 1 element

Comprehensive
HPI 4 elements or 3 chronic conditions
ROS 10 elements
PAST 1 element from medical, family & social

II. Exam

Problem focused 1 element
Expanded problem focused six elements
Detailed 2 elements in 6 areas
Comprehensive 2 elements from 9 areas

III. Medical decision making

Straight forward none
Low complexity 2 dx
Two minor problems and on OTC drugs
Two established problems and on OTC drugs
One established problem worse and on OTC drugs
Moderate complexity 3 dx
Three stable problems and on prescription drugs
One new problem requiring no work-up and on
prescription drugs
One established problem but worse and one stable
problem and on prescription drugs

High complexity 4 dx
Four stable problems and IV narcotics or DNR or peritonitis
or ARF or drug therapy requiring intensive monitoring or
coronary angiography or SZ or TIA or weakness or sensory
loss or multi-truama or acute MI or PE or severe resp distress
or progressive severe rheumatoid arthritis or psychosis with
threat to self or others or other illness/injury that poses a threat
to life or bodily function or chronic illness with severe
exacerbation, progression or side effect of tx

Four stable problems and review/order lab and review/order
radiology and discuss test result with performing MD and
obtain old records

Four stable problems and independent visualization of image,
tracing or specimen and discuss case with other healthcare provider

Four stable problems and independent visualization of image,
tracing or specimen and review & summarize old record or obtain
history from source other than pt

Substitute one new problem requiring work-up instead of 4 stable
problems above

Substitute one established problem and two stable problems instead
of 4 stable problems above

Substitute one new problem and one stable problem instead of 4 stable
problems above

Outpatient arena:

History: (f/u pt levels 1, 2 , 3 & new pt levels 1, 2 = 1 element; f/u pt levels 4, 5 & new pt levels 3, 4, 5 = 4 elements or status of 3 chronic conditions – context / severity / duration / associated signs & symptoms / ameliorating or aggravating factors / location /
quality / timing)

ROS: (f/u pt levels 1, 2 & new pt level 1 = none; f/u pt level 3 & new pt level 2 = 1; f/u pt level 3 , 4 & new pt level 3 = 2; f/u pt level 5 & new pt level 4, 5 = 10)

PAST: (f/u pt level 1, 2, 3 & new pt level 1, 2 = none; f/u pt level 4 & new pt level 3 = 1 of any; f/u pt level 5 & new pt level 4, 5 = 1 from each)

EXAM: (f/u pt level 1 = 0; f/u pt level 2 & new pt level 1 = 1; f/u pt level 3 & new pt level 2 = any 6; f/u pt level 4 & new pt level 3 = any 12; f/u pt level 5 & new pt level 4, 5 = 2 in 9 areas)

Medical Decision Making: (f/u & new pt level 1, 2 = _ 1 dx; f/u & new pt level 3 = 2 dx; f/u & new pt level 4 = 3 dx; f/u & new pt level 5 = 4 dx)

Second approach

UNIVERSITY INTERNAL MEDICINE ASSOCIATES LLP
SUBSEQUENT INPATIENT VIST (FOLLOW-UP)
TEMPLATE

Level 2 (99232)

History: Expanded Problem-Focused
One to three history elements
One system element reviewed
No Past, Family, or Social history

Exam: At physician discretion
(>/= 6 elements, if no history)

Medical Decision Making (A/P): MODERATE LEVEL
3 stable problems, no changes OR
one new problem requiring no w/u OR
one old problem that is worse and one stable problem
Moderate Risk category = on prescription meds

Level 3 (99233)

History: Detailed
Four history elements (or status of 3 chronic problems)
2 systems elements (minimum)

Exam: At physician discretion
(>/= 12 elements if no history)

Medical Decision Making (A/P): HIGH LEVEL
4 stable problems, no changes OR
one new problem requiring w/u OR
one old problem that is worse and two stable problems

High Risk category = on parenteral narcotics or
DNR discussion, or potentially life-threatening
problem. etc.

INITIAL INPATIENT VISIT
TEMPLATE

Level 2 (99222)

History: Comprehensive
2 four history elements or status of 3 chronic conditions
10 systems reviewed (“all others negative”)
One element from Past, Family, and Social history

Exam: 2 bullets from 9 body areas

Medical Decision Making (A/P): MODERATE LEVEL
3 stable problems, no changes OR
one new problem requiring no w/u OR
one old problem that is worse and one stable problem
Moderate Risk category = on prescription meds

Level 3 (99223)
History: Comprehensive
2 four history elements or status of 3 chronic conditions
10 systems reviewed (“all others negative”)
One element from Past, Family, and Social history

Exam: 2 bullets from 9 body areas

Medical Decision Making (A/P): HIGH LEVEL
4 stable problems, no changes OR
one new problem requiring w/u OR
one old problem that is worse and two stable problems

Data includes lab, x-ray, and either old chart review,
OR personal review of x-ray, OR consult, OR history
from other than patient

High Risk category = on parenteral narcotics or DNR
discussion, or potentially life-threatening problem, etc.

ESTABLISHED OUTPATIENT VISIT
TEMPLATE

Level 3 (99213)
History: Expanded Problem Focused
One history element (minimum)
One system reviewed (minimum)
No Past, Family, and Social History

Exam: At physician discretion
(>/= 6 bullets, if no history)

Medical Decision Making (A/P): LOW LEVEL
2 established – stable problems, no changes OR
1 established – stable problem. worsening

Low Risk Category = NIDDM. We||-contro|led HTN, OTC drugs

Level 4 (99214)
History: Detailed
2 four history elements or status of 3 chronic conditions
2 systems reviewed (minimum)
One element from Past, Family. or Social History

Exam: At physician discretion
(12 bullets. if no history)

Medical Decision Making (A/P): MODERATE LEVEL
3 established – stable problems, no changes OR
one new problem requiring no w/u OR
one old problem, worsening and one stable problem

Mod. Risk Category = on prescr. meds, 2 stable chron. Illn.

Level 5 (99215)

History: Comprehensive
2 four history elements or status of 3 chronic conditions
10 systems reviewed or “all others negative”
Two elements from Past, Family, and Social History

Exam: At physician discretion
(2 bullets from 9 areas / systems, if no history)

Medical Decision Making (A/P): HIGH LEVEL
4 established stable problems, no changes OR
one new problem requiring w/u OR
one old problem worsening and two stable problems

Data includes lab, x-ray, and either old chart review,
OR personal review of x-ray. OR consult. OR history
from other than patient

High Risk category = on parenteral narcotics, DNR
discussion. or potentially life~threatening problem

NEW OUTPATIENT VISIT
TEMPLATE

Level 3 (99203)

History: Detailed
>/= four history elements or status of 3 chronic conditions
2 systems reviewed (minimum)
One element from Past, Family, OR Social history

Exam: Detailed
12 bullets

Medical Decision Making (A/P): LOW LEVEL
2 established — stable problems, no changes OR
1 established – stable problem, worsening

Low Risk Category = NIDDM, Well-controlled HTN, OTC drugs

Level 4 (99204)

History: Comprehensive
>/= four history elements or status of 3 chronic conditions
10 systems reviewed or ”all others negative”
One element each from Past, Family, and Social history

Exam: Comprehensive
2 bullets from 9 areas / systems

Medical Decision Making (A/P): MODERATE LEVEL
3 established — stable problems, no changes OR
one new problem requiring no w/u OR
one old problem, worsening and one stable problem

Mod. Risk Category = on prescr. meds, 2 stable chron. illn.

Level 5 (99205)

History: Comprehensive
>/= four history elements or status of 3 chronic conditions
10 systems reviewed or ”all others negative”
One element each from Past, Family, and Social history

Exam: Comprehensive
2 bullets from 9 areas / systems

Medical Decision Making (A/P): HIGH LEVEL
4 established — stable problems, no changes OR
one new problem requiring w/u OR
one old problem worsening and two stable problems

Data includes lab, x-ray, and either old chart review,
OR personal review of x-ray, OR consult, OR history
from other than patient

High Risk category = on parenteral narcotics, DNR
discussion, or potentially life-threatening problem

Billing encounter form