What is a 99223 for E and M coding?

The CPT code 99223 is the highest level of service that can be billed for an initial visit for a patient being admitted to the hospital.  This code is to be used as an E and M code for inpatients only. The code 99223 is similar to the outpatient code 99205 both levels of service require a high risk complaint.  

The E and M code 99223 is the specific code for a new inpatient visit that has a high-risk complaint and requires a high amount of history, exam and medical decision making.  This E and M code is used frequently by admitting physicians. The reason for the high use is due to the simple fact that if a patient requires admission to the hospital then they typically have a condition that could threaten life or limb.. 

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For a new patient, all 3 components must be met.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality, and timing

  2. Past medical family and social history

  3. Review of Systems – 14 recognized systems

  • Constitutional (e.g., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/Immunologic 

2.) Exam- The physical exam component is comprised of  

  • Constitutional (e.g., vital signs, general appearance)

  • Eyes

  • Ears, nose, mouth, and throat 

  • Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  • Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3. Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For a new patient 99223 the following items must be met for each of the three components.

  • History – Four element of HPI, ten systems reviewed, and three PMFSH reviewed

  • Exam- eight systems examined

  • High risk complaint and needs to have either: Four diagnosis, four treatment option or four data review.

Example: 99223

51 yo male has admitted to the hospital for acute onset left arm and leg paralysis for 3 hours prior to arrival to the ER.   The patient states the symptoms improving since receiving TPA in the Ed.  At the time of the visit, the patient states associated symptoms are headache, neck pain left leg paralysis and left arm paralysis.

PMFSH  - all reviewed

ROS – Neuro - positive Headache, left leg and arm paralysis 

            Musculoskeletal – positive for neck pain

             Eight other systems reviewed and negative (need each documented in the note)

 

Exam – General – well developed well-nourished 

 

Neuro–1/5 motor noted to left leg and left arm, left-sided facial droop noted on exam.

 

Six other systems examined (all eight systems must be documented n the note

 

Diagnosis – 1.) Left leg paralysis

                      2.) left arm paralysis

                      3.) Headache

                       4.) Neck pain

Plan  -

  1. Admit to ICU

  2. MRI in a.m.

  3. PT Consult in a.m.

  4. Echocardiogram in a.m.

  5. Carotid US 

  6. Repeat labs in a.m.

  • (HPI components)

  • (ROS systems)

  • (Systems examined ENT detailed)

As you can see from the above example or a 99223 the complexity of patients very high and most likely life-threatening due to the, therefore, the level of risk is higher and CMS will pay you more for that level of service.   As you would expect with more complex patients CMS expects more exams to be performed and history to be taken.

 

The other option for billing for Evaluation and management codes is the unit of time.  For a 99223 the practitioner must spend at least 70 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All these components should be documented.