When circumstances present, it’s important to know the appropriate inpatient service codes.

In 2021, we saw significant changes to the coding instructions for office and outpatient evaluation and management (E/M) codes, compliments of the AMA. Since then, ophthalmologists, optometrists, and coders have had to rethink their charting habits and coding patterns for office visits. The 2021 instructions did not impact codes used in a variety of inpatient settings.

That changes this month. Effective January 2023, selecting the level of E/M code based solely on medical decision making or physician time spent will also apply to claims for services provided in nursing facilities, inpatient hospital settings, and emergency department settings.

Most ophthalmic encounters are office based, so these 2023 changes are likely to have little impact on eye-care practices. However, when circumstances present, it is important to know the inpatient service codes and how to select the level of service.

Time-based coding

The 2021 AMA instructions¹ allow coders to consider more than face-to-face time when determining the level of service base on physician time. The instructions state:

“For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

Physician/other qualified health care professional time includes the following activities, when performed:

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (when not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)”

Hospital care

Coding based on physician time spent is not usually the best choice for office-based ophthalmic visits; however, in an inpatient setting, it may make sense. Table 1 includes the time requirements for each category of inpatient codes.

The 2023 CPT manual provides instructions on billing for admitting a patient as an inpatient or to observation status in addition to an encounter in another site of service (e.g., office, emergency room, or nursing facility). The services in the initial setting may be separately reported; modifier 25 may be added to the E/M code for the initial site.²

Emergency Department codes (Table 2) are assigned based only on medical decision making; time-based coding is not an option due to variable intensity often involving multiple counters with several patients over an extended period of time.

Nursing facility and home care

The nursing facility codes (Table 3) apply to E/M services provided to patients in nursing facilities, skilled nursing facilities, psychiatric residential treatment centers, and immediate care facilities. Similar to the discussion about hospital admissions above, when an admission to a nursing facility occurs in the course of a same-day encounter in another site (e.g., emergency department or office), the service in the initial site may be separately reported; use modifier 25.

When a consultation is performed by the same physician, the consultant reports the subsequent nursing facility care codes (99307 – 99310) for the second service on the same day.

Initial nursing facility care codes (99304 – 99306) are for use by the “initial” physician overseeing the patient (i.e., admitting). Other providers provide concurrent care, specialty care, or consultation. Refer to codes 99307-99210 for inpatient consultation codes in series 9925x.

While Medicare no longer recognizes or reimburses for consultation codes, other third-party payers may.

Conclusion

With luck, your ophthalmologists and coders have already mastered the E/M coding instructions — they have been in place for 2 years. The 2023 changes simply apply these coding guidelines to the E/M services provided in inpatient settings. Pay close attention to these claims, and keep a 2023 CPT book nearby for reference, if needed. OP

REFERENCES:

1. AMA. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes. www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf . Accessed November 28, 2022.
2. AMA. 2023 E/M Guidelines in CPT. www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf . Accessed November 28, 2022.

Ms. Johnson is a Certified Professional Medical Auditor and a Certified Professional Coder by the American Academy of Professional Coders. She has also obtained the Certified Ophthalmic Executive (COE) designation. Ms. Johnson conducts business from the Corcoran Consulting Group’s North Carolina office.