New CPT codes: hospital, consultation, emergency and nursing facility services - Current Procedural

Author: Thomas J. Zuber, Douglas E. Henley
Date: March, 1992

The evaluation and management codes for 1992 represent an entirely new classification and reporting system for physician services. New definitions were developed to provide a uniform system for reporting the key clinical elements of each level of service. The new definitions were discussed in an article in last month's issue(l) and are found in the current procedural terminology (CPT) code book published in 1992 by the American Medical Association. (2) Time factors are included in the 1992 codes to assist physicians in code selection. The specific times expressed in the code descriptors are averages, and they may be higher or lower, depending on the actual patient encounter. Only when counseling or coordination of care dominates the visit (more than 50 percent) is time considered the controlling factor.(2,3)

This article focuses on new classifications and definitions of the hospital inpatient codes, consultation codes, emergency department service codes and nursing facility service codes.

Hospital Inpatient Services

The 1992 CPT code book includes three levels of services for both initial inpatient and subsequent inpatient hospital care (Table 1). Codes for initial inpatient services involve a comprehensive history and physical examination for both new and established patients, and vary only with the level of medical decision making. Services provided in another location (e.g., office, nursing home, emergency department) to determine the need for admission are considered part of the initial hospital care and are included in the codes for initial inpatient services.

The inpatient services code definitions describe average times for physician services provided at the bedside and on the patient's hospital floor or unit. Inpatient codes differ from outpatient codes, which use time descriptors for actual face-to-face time spent with a patient.

An example of a first-level initial inpatient visit (99221) would be the admission of an 18-month-old child with 10 percent dehydration. A 99222 visit code would describe the direct admission of a young adult patient with an acute asthmatic attack that failed to respond to previous therapy. A third-level initial inpatient visit (99223) might be the admission of a 78-year-old woman with pneumonia and a history of angina, congestive heart failure and gout.

The three codes describing subsequent hospital care include review of the medical record, review of the results of diagnostic studies and review of changes in the patient's status since the previous visit by the physician. The 99231 visit usually describes the care for a patient who is stable or recovering, such as the follow-up of a 50-year-old man who is recovering from a myocardial infarction and is stable and pain-free. The second-level subsequent inpatient visit (99232) describes the care for a patient who is responding inadequately to therapy or who has developed a minor complication. The 99232 visit might describe the infarction patient above who is released from the coronary care unit and develops frequent premature ventricular contractions. The 99233 visit code is generally reserved for patients who are unstable or who have developed a significant complication or new problem. The follow-up hospital visit for a 60-year-old woman who develops severe chest pain, dyspnea and diaphoresis four days after an uncomplicated inferior myocardial infarction would be reported with the 99233 code.

The hospital discharge services code for 1992 has been changed to 99238.(2) This code describes the services provided on the final day of a multiple-day hospital stay. Services included in this code are final examination of the patient, discussion of the hospital stay, instructions for follow-up care and preparation of discharge records.

The concurrent care modifier "-75" has been deleted.(2,4) Men care is provided to a patient by more than one physician concurrently, no special reporting is required. Physicians are encouraged to contact third party payers to determine local reimbursement rules for concurrent care.

The critical care subsequent follow-up visit codes (99171 to 99174)(5) have been eliminated in 1992. Critical care should be reported according to the total time spent by a physician providing constant attention to a critically ill patient. Critical care is usually, but not always, given in a critical care area.

Code 99291 is used to report the first hour of critical care on a given day. Code 99292 is used to report each additional 30 minutes beyond the first hour. For example, if a patient required one hour of critical care in the afternoon and two hours of critical care that evening, the physician would report code 99291 once and code 99292 four times for the services provided that day.(2)

Services provided during the critical care period, such as placement of central intravenous lines, endotracheal intubation or tube thoracostomy, are included in the critical care time codes. Other procedures performed that are not directly attendant to critical care management are not included in critical care. Suture repair of lacerations and setting of fractures are examples of noncritical care procedures that should be reported separately.

Consultations

Consultation is defined as a physician's opinion or advice regarding the evaluation and management of a specific problem. The request for a consultation by the attending physician (or other appropriate sources), as well as the need for a consultation, must be documented in the medical record. The medical record should also reflect the consultant's opinion and the diagnostic services that were ordered or performed and should indicate that the consultant's opinion was communicated to the requesting physician.

There are four subcategories for consultations in the 1992 CPT code book: office/outpatient, initial inpatient, follow-up inpatient and confirmatory.

OFFICE/OUTPATIENT CONSULTATIONS

The office/outpatient consultation codes apply to consultative services performed in any outpatient setting. No distinction is made between new or established patients for these codes. The codes, key components and average times are listed in Table 2.

The outpatient consultation codes can be used in the emergency department setting. When an emergency department physician initially manages a case and subsequent evaluation by the attending physician allows the patient to be discharged home, the attending physician should report an outpatient consultation. If the patient is admitted to the hospital, the initial hospital services codes apply. This application of the outpatient consultation codes should prevent the problem of denial of payment from third-party payers when both emergency department physicians and attending physicians bill for emergency services on the same day.

The first level of outpatient consultation (99241) would describe, for example, the surgical evaluation of a 25-year-old woman who has symptomatic hemorrhoids after delivery. The 99242 code would be used to report office consultation for management of systolic hypertension in a 70-year-old man who is scheduled for elective prostate surgery. The third level of outpatient consultation (99243) would be used to report the initial office consultation by the physician of a 65-year-old man who has chronic back pain and radiculopathy. Code 99244 would describe office consultation for a referred diabetic patient who is contemplating pregnancy. The fifth level of outpatient consultation (99245) would be used for the initial office consultation of a 43-year-old man with fulminant hepatic failure and encephalopathy.

INITIAL INPATIENT CONSULTATIONS

The inpatient consultation codes are used to report consultations provided to hospital inpatients or residents of nursing facilities. Only one initial consultation should be reported by an individual consultant for each admission. No distinction is made between new or established patients for these codes. The codes, key components and average time spent at the bedside or on the hospital floor or unit are listed in Table 3.

The first level of inpatient consultation (99251) would describe, for example, the initial hospital consultation for a 45-year old woman who has had a cholecystectomy and complains of a foreign-body sensation in her eyes. Code 99252 would describe the initial hospital consultation for a 55-year-old diabetic patient taking an oral hypoglycemic agent, who is scheduled for a cholecystectomy. The third level of inpatient consultation (99253) would describe the evaluation and management of a patient with a fever after abdominal surgery. Code 99254 would apply for the initial hospital consultation for a 65-year old woman who suddenly develops fever and delirium on the second postoperative day. The fifth level of inpatient consultation (99255) would describe the initial evaluation performed in an intensive care unit for a 70-year-old man who had a cardiac arrest during surgery and was resuscitated.

FOLLOW-UP INPATIENT CONSULTATIONS

Follow-up inpatient consultations are defined as those hospital visits used to complete the initial consultation or as subsequent consultative visits requested by the attending physician. If the physician consultant initiated treatment at the first consultation, the codes for subsequent hospital care would be used to report subsequent visits. Follow-up consultation codes are used when a consultant needs more than one patient visit before rendering an opinion. The follow-up consultation codes, key components and average time spent at the bedside or on the hospital floor or unit are listed in Table 4.

CONFIRMATORY CONSULTATIONS

The confirmatory consultation codes should be used whenever a consulting physician is aware that a confirmatory opinion is sought. These codes apply when the patient or the patient's family initiates the request for a physician consultation. If a third-party payer calls for a confirmatory consultation, the modifier -32" or 00932 (mandated services) should also be reported.

The confirmatory consultation codes apply in new or established patients. The typical times spent providing these services have not yet been established. Table 5 lists the confirmatory consultation codes and key components.

Emergency Department Services

The 1992 CPT code book defines an emergency department as an organized hospital-based facility that provides unscheduled episodic emergency services 24 hours per day.2 No distinction is made between new and established patients in the emergency department. All physicians, whether based in the emergency department or not, may use the five emergency department codes (Table 6).

An example of a 99281 emergency department visit is the examination of a patient presenting with minor insect bites. A second-level visit (99282) would describe the examination of an uncomplicated inversion injury of the ankle, with or without radiographic examination. Code 99283 would apply for the evaluation of a patient after an isolated, closed head injury without loss of consciousness. The fourth-level emergency department visit code (99284) would be appropriate for the evaluation and management of a patient presenting with abdominal pain, when the diagnosis of ectopic pregnancy is strongly suspected. Code 99285 would be used for a 65-year-old insulin dependent diabetic who is treated for ketoacidotic coma and uremia.

Nursing Facility Services

All nursing facility services will be reported in 1992 as either a comprehensive nursing facility assessment or a subsequent nursing facility care visit (Table 7). These two classifications will apply to either new or established patients. Evaluation and management of domiciliary or nursing home patients are not reported as nursing facility services.

Comprehensive nursing facility services may describe the annual general examination or the examination at admission to the nursing facility. The examination may be performed at one or more sites and generally includes services provided in all settings in conjunction with admission to the nursing facility. The exception to this rule occurs when a patient is admitted to the nursing facility after admission to a hospital. Hospital discharge services (99238) may be reported in addition to the comprehensive nursing facility admission assessment. This change in the coding rules should allow more appropriate reimbursement for the extensive work required to complete hospital records and initiate nursing facility care.

The first level of comprehensive nursing facility assessment (99301) usually describes a patient who is stable, recovering or improved. This code might apply to the annual assessment of a resident with Alzheimer's disease who has no other organ system problems. The code 99302 describes the assessment of a patient with a significant complication or significant new problem, who has had a major, permanent change in status. This code is used when the creation of a new medical care plan is required. For example, the 99302 code would be used to describe the assessment of a 75-year-old patient with diabetes who was previously controlled with oral hypoglycemic agents but now requires insulin therapy. The third-level code (99303) would be used to describe the initial nursing facility examination and the initiation of a treatment program for an 80-year-old hypertensive patient with a recent cerebrovascular accident.

In 1992, subsequent nursing facility care will be reported for patients who do not require a comprehensive assessment or who have not had a major, permanent change of status. The subsequent nursing facility care codes apply in either new or established patients. All levels of subsequent care include review of the medical record, review of changes in patient status and review and signing of orders.

The 99311 code usually describes the evaluation and management of a patient who is stable, recovering or improving. The monthly nursing facility visit for a stable 70-year-old paraplegic patient would be described with this code. The second level of subsequent nursing facility care (99312) usually describes a patient who is responding inadequately to therapy or who has developed a minor complication. For example, code 99312 would describe the subsequent visit for a 65-year-old patient who had a stroke six months previously and has developed a fever and cough. The third-level visit (99313) is reserved for patients who develop a significant complication or a new problem. Code 99313 would describe a nursing facility visit for a 78-year-old woman with chronic atrial fibrillation who develops an acute confusional state and needs a revised medical care plan.

The 1992 CPT book lists new and established patient codes for domiciliary or nursing home services.(2)when a nursing home patient is examined in the nursing home, these new codes (99321 to 99333) apply. Nursing home patient examinations that take place in the physician's office are reported with the off ice evaluation and management codes. The American Medical Association plans to publish clinical examples of domiciliary and nursing home visits early in 1992.

Final Comment

The new evaluation and management codes for 1992 represent a significant change in reporting most of the major cognitive services provided by family physicians. Besides reading the 1992 CPT book, physicians should watch for other publications that will assist with the use of the new codes. Although the clinical examples for each new code were tested by specific specialty groups, the examples can be used by all specialists. Family physicians may use any clinical example that if its their particular practice pattern.

The new evaluation and management codes will replace the 1991 codes and are in the Medicine Section" of the 1992 CPT book as 99000 codes. Although all Medicare carriers are required to use the new codes, other insurance carriers will determine whether or when they will follow suit. Physicians should keep their 1991 CPT code books so they can report the old office level-of-service codes to carriers that are not using the new codes early in 1992. Physicians are urged to contact local insurance carriers to learn which codes they will be using.

REFERENCES

1. Zuber Tj, Henley DE. A guide to the new

office evaluation and management codes for

1992. Am Fam Physician 1992;45:703-8.

2. American Medical Association. CPT 1992:

physicians' current procedural terminology.

Chicago: American Medical Association,

1992.

3. American Medical Association. Department

of Coding and Nomenclature. Evaluation and

management (E/M) coding: a facilitator's

guide. Chicago: American Medical Association,

1991.

4. Medicare program: fee schedule for physician

services. Proposed rule. Fed Regist 1991;56:

25791-978.

5. American Medical Association. CPT 1991:

physicians' current procedural terminology.

4th ed rev. Chicago: American Medical Association,

1991. TABULAR DATA OMITTED

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