Secrets to Subsequent Hospital E/M Coding Success

coding for hospital visits

Curious how your use of subsequent hospital visit codes compares to reporting by other practices? Palmetto was curious, too. The Part B MAC took part in developing a Comparative Billing Report (CBR) looking at 99231-99233 billing and payment patterns in 2015 for internal medicine providers. Motivation? Those codes see about a billion dollars in improper Medicare payments each year. Keep your hospital visit reporting on the up and up by getting to know the codes and common problem areas.

Did the Case Really Earn 99233?

One of the areas the CBR looked at is the percentage of total services reported as high-level code 99233. Nationally, the rate was 32 percent, but percentages varied state to state. For instance, Wyoming averaged 20 percent, but Arizona averaged 53 percent!

We can’t know from these numbers whether anyone is coding inappropriately. It’s possible the patient population in one area consistently requires higher level services than the patient population in another area. What you can do is look at your own usage patterns to see if you vary widely from your state. And, of course, make sure you’re coding each case based on the documentation available, with special attention to whether the medical necessity of the case supports the code level assigned.

Here are the elements in each code:

  • Elements applicable to all three codes
    • Subsequent hospital E/M
    • Reported per day
  • 99231
    • 2 of these 3 key components:
      • Problem focused interval history
      • Problem focused exam
      • Straightforward or low complexity medical decision making (MDM)
    • Patient is stable, recovering, or improving
    • 15 minutes at bedside and on floor/unit typical
  • 99232
    • 2 of these 3 key components:
      • Expanded problem focused interval history
      • Expanded problem focused exam
      • Moderate complexity MDM
    • Patient is not responding adequately or has a minor complication
    • 25 minutes at bedside and on floor/unit typical
  • 99233
    • 2 of these 3 key components:
      • Detailed interval history
      • Detailed exam
      • High complexity MDM
    • Patient is not stable, has a significant complication, or has a significant new problem
    • 35 minutes at bedside and on floor/unit typical

Keep the Documentation Focus on Quality Not Quantity

Based on problems commonly seen, Palmetto staff offered some areas to watch to ensure your 99231-99233 documentation is up to snuff:

  • Easier to spot: Incomplete/illegible notes, lack of documentation, unclear dates of service, problems with provider signature
  • Tougher to spot: Lack of medical necessity — base code choice on complexity supported by the documentation, not just the amount of documentation.

Bonus: When to Report Subsequent Code for Initial Visit

Let’s take your hospital visit know-how up another notch by going over an interesting oddity of Medicare reporting. When Medicare stopped accepting consultation E/M codes, it created some problems for reporting initial hospital services that didn’t meet the requirements for reporting an initial hospital visit code. Medicare’s solution is to allow you to report a subsequent hospital care code that describes the work and medical necessity requirements even when it’s the provider’s first inpatient service during the stay. You’ll find the rule in Medicare Claims Processing Manual, Chapter 12, Section 30.6.10.

What About You?

Do you have tips for choosing between the different code levels and getting the documentation you need?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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