Coding multiple new problems
Patients frequently present with multiple new acute problems or with one new acute problem and one new minor problem. In such cases, how can I use the risk table and the “number of diagnoses/treatment options” section of a medical decision making template to get what I feel is sufficient credit for my medical decision making?
The medical decision making component of the E/M codes represents the total medical decision making involved in the encounter. As such, it is cumulative with respect to the number of presenting problems being addressed. The documentation guidelines state that “the number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during that encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician” [emphasis added]. More problems mean more diagnoses and management options to consider, potentially more data to be reviewed and potentially a greater level of risk. For example, if a patient presents with a new problem and a minor, self-limited problem, you would “get credit” for both.The Table of Risk reflects the same principle. For example, one stable chronic illness is “low” risk, but two or more stable chronic illnesses is “moderate” risk. However, for the purposes of assessing risk, you cannot add two “moderates” (such as an acute illness and an undiagnosed new problem) to get a “high.” Rather, the highest level of risk in any one category determines the overall risk.
Swing-bed status
Our critical-access hospital has a “swing-bed” status on its medical/surgical unit for patients who do not need acute inpatient care but do need intermediate or basic nursing or ancillary care services. Which CPT codes should I submit for same-day inpatient discharge and swing-bed admission, daily visits to swing-bed patients, swing-bed admission from outside the hospital, and swing-bed discharge to home? Also, does the critical-access status of our hospital affect the codes?
Regarding visits to patients in swing beds, the Medicare Carriers Manual states that “if the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.” Therefore, to code services to swing-bed patients correctly, you need to know how the hospital is billing for its care. When the hospital is billing the patient’s care as inpatient hospital care, you should submit initial hospital care codes (99221–99223) for admission to the swing bed, subsequent hospital care codes (99231–99233) for subsequent daily visits, and 99238 or 99239 for discharge. Alternatively, when the hospital is billing the patient’s care as nursing facility care, you should submit the subsequent nursing facility care codes (99311–99313) for daily visits, 99303 for admission from outside the hospital, and the appropriate nursing facility discharge code (99315 or 99316) for discharge to home. When a patient is discharged as an inpatient and admitted to swing-bed status for nursing facility care, submit a hospital discharge day code (99238 or 99239) for the discharge and a nursing facility admission code (e.g., 99303) for the admission. The critical-access status of your hospital should not make a difference in these coding scenarios, but it will impact the hospital’s reimbursement for its services.
Editor’s note: While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding and documentation recommended. Because CPT and ICD-9 codes change annually, you should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.
