Help needed with inpatient billing codes

[jbomba]

Hi - so I understand billing codes are 99231, 99232, and 99233. Have read about when to bill each, but still feel things are somewhat vague. Can anyone provide examples and/or have a helpful chart that might make things easier for me? Thanks.

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[comp1]

Good question, but I've never seen anything used other 99233. If they're meeting criteria for 99231...I'm not sure they should still be in the hospital.

 

[Stagg737]

Good question, but I've never seen anything used other 99233. If they're meeting criteria for 99231...I'm not sure they should still be in the hospital.

My attendings typically used 99232 for most patients. We did occasionally have patients that would be stuck on our unit for weeks awaiting placement, those would be the ones getting billed 99231s until CMS or insurance decided to stop covering them.

 

[psych_0]

1. If I'm making med changes that day = 99233. If patient had ECT that day = 99233. If I'm ordering or reviewing labs (and thus, making med decisions based on this) = 99233. If I'm ordering a neuro consult or imaging and making decisions based on the results = 99233.
2. If no med changes = 99232. If they're stable just waiting to get into rehab (i.e. finishing an ETOH detox, etc) or dc next day = 99232.
3. Rare case where the person is on the wait list for state hospital and just in a holding pattern, not making any med changes = 99231

The only time I'm billing multiple 99231s in a row is if they're just waiting for placement and I have no where to send them. Typically, insurance has already asked for a peer-to-peer and told me my care in "custodial in nature" by then.

I probably bill 89% 99233, 10% 99232, and 1% 99231.

New intakes are 90792 no matter what. Even if the ED keeps letting in the same homeless malingerer 3 days in a row. Bless the man/woman who negotiated the new wRVU rate for 90792 to be increased to 4.16 in 2021. I can't imagine that lasts forever, but it's very sweet right now.

 

[J ROD]

231 only when stable and waiting on placement
232 mostly for improving not acute
233 acute psychosis getting im shots seclusion etc. suicidal homicidal or if I tend to spend more than 35 min doing care including medical and taking to court. I tend to spend over 35 min on those days with a patient. My interview chart review and time with judge

 

[psych_0]

231 only when stable and waiting on placement
232 mostly for improving not acute
233 acute psychosis getting im shots seclusion etc. suicidal homicidal or if I tend to spend more than 35 min doing care including medical and taking to court. I tend to spend over 35 min on those days with a patient. My interview chart review and time with judge

Agreed. If I go to court, that is a 99233

 

[forchinet121]

1. If I'm making med changes that day = 99233. If patient had ECT that day = 99233. If I'm ordering or reviewing labs (and thus, making med decisions based on this) = 99233. If I'm ordering a neuro consult or imaging and making decisions based on the results = 99233.
2. If no med changes = 99232. If they're stable just waiting to get into rehab (i.e. finishing an ETOH detox, etc) or dc next day = 99232.
3. Rare case where the person is on the wait list for state hospital and just in a holding pattern, not making any med changes = 99231

The only time I'm billing multiple 99231s in a row is if they're just waiting for placement and I have no where to send them. Typically, insurance has already asked for a peer-to-peer and told me my care in "custodial in nature" by then.

I probably bill 89% 99233, 10% 99232, and 1% 99231.

New intakes are 90792 no matter what. Even if the ED keeps letting in the same homeless malingerer 3 days in a row. Bless the man/woman who negotiated the new wRVU rate for 90792 to be increased to 4.16 in 2021. I can't imagine that lasts forever, but it's very sweet right now.

Why is it so sweet? Other specialties still make far more with procedure codes and have been for decades, why do you think this will go away?

 

[ObsequiousAplomb]

Why is it so sweet? Other specialties still make far more with procedure codes and have been for decades, why do you think this will go away?

It's sweet because if you have admitted someone three times in one week there's very little work to do for 4 wRVUs. Sure, other specialties can make more per hour, but that's other specialties performing procedures that aren't as easy as copy-forwarding the last H&P with three new lines of HPI.

 

[nexus73]

I'm not sure how to justify 99233 on so many patients. Our hospital anyways requires medical decision making to be used as one of the 2/3 required components for billing. I thought medicare made that an inpatient requirement. The challenge with using med decision making is you'll never get enough data points (or rarely), and for a follow up patient unlikely you'll have a new problem, so you've gotta have 4 problems you're managing to meet criteria for 99233.

 

[psych_0]

I'm not sure how to justify 99233 on so many patients. Our hospital anyways requires medical decision making to be used as one of the 2/3 required components for billing. I thought medicare made that an inpatient requirement. The challenge with using med decision making is you'll never get enough data points (or rarely), and for a follow up patient unlikely you'll have a new problem, so you've gotta have 4 problems you're managing to meet criteria for 99233.

For a 99233 you technically only need 2 elements out of :

• Interval Hx (4 HPI + 2 ROS)
• physical exam
• MDM
• Time (>35 min).

 

[nexus73]

For a 99233 you technically only need 2 elements out of :

• Interval Hx (4 HPI + 2 ROS)
• physical exam
• MDM
• Time (>35 min).

Yes billing on time is fine. Our hospital requires MDM be one of the 2 elements.

 

[Wheatbread]

Probably use 90% 99233, 10% 99232 on adult psych unit. My criteria is either unstable or med changes = 99233. Unstable means threat to self or others, which is vast majority. I use 99232 if no med changes and waiting on bed elsewhere. If they don’t fall in one of those categories they get discharged.

 

[AD04]

@Wheatbread @psych_0

Thanks for describing how you determine inpatient follow up billing code. How does your criteria meet the high risk of MDM? Do you commonly have 4 problem points as well or do insurance companies and Medicare not look too deeply into that?

How long have you been billing the majority of inpatient follow ups as 99233? Did you go through any audits and successfully justify your stance?

Edit:

I've been reading more about inpatient MDM criteria here:

New office patients (99201-99205) - E/M Coding Education, EM evaluation and management coding, e&m documentation, 99214, 99213

I didn't realize that risk level only needed ONE element. It is quite easy to reach high risk level. I now see how I've been under-coding. Thanks for bring this to my attention.

 

[Wheatbread]

@Wheatbread @psych_0

Thanks for describing how you determine inpatient follow up billing code. How does your criteria meet the high risk of MDM? Do you commonly have 4 problem points as well or do insurance companies and Medicare not look too deeply into that?

How long have you been billing the majority of inpatient follow ups as 99233? Did you go through any audits and successfully justify your stance?

Edit:

I've been reading more about inpatient MDM criteria here:

New office patients (99201-99205) - E/M Coding Education, EM evaluation and management coding, e&m documentation, 99214, 99213

I didn't realize that risk level only needed ONE element. It is quite easy to reach high risk level. I now see how I've been under-coding. Thanks for bring this to my attention.

Yeah, if you look at the link you included, if you go under Risk, you’ll see that a chronic illness exacerbation with threat of self or others pretty much qualifies as high MDM. I’ve spent a decent amount of time talking with our auditors, get an internal audit every quarter and been fine for 2 years.

 

[nexus73]

Yeah, if you look at the link you included, if you go under Risk, you’ll see that a chronic illness exacerbation with threat of self or others pretty much qualifies as high MDM. I’ve spent a decent amount of time talking with our auditors, get an internal audit every quarter and been fine for 2 years.

I understand how it is high risk but how is it enough problem points?

 

[AD04]

I understand how it is high risk but how is it enough problem points?

Be thorough in your interview and documentation. The unstable psychiatric condition is 2 points. You need a minimum of 2 more points. Restarted home medication for HTN and DM? Document that and that's 2 points. Cigarette smoker offered nicotine replacement therapy? Another point. Patient drinks too much alcohol but refuses naltrexone? Another point. Patient complaining of insomnia in the hospital and you're offering PRN? Another 1 - 2 points.

 

[jbomba]

Be thorough in your interview and documentation. The unstable psychiatric condition is 2 points. You need a minimum of 2 more points. Restarted home medication for HTN and DM? Document that and that's 2 points. Cigarette smoker offered nicotine replacement therapy? Another point. Patient drinks too much alcohol but refuses naltrexone? Another point. Patient complaining of insomnia in the hospital and you're offering PRN? Another 1 - 2 points.

Is there a document or something I can Google that has this information. Tbh it sounds foreign to me as a still resident just begining to moonlight

 

[psych_0]

Yes billing on time is fine. Our hospital requires MDM be one of the 2 elements.

I never said you have to bill on time. Read the other 3 options. Those are all easy to hit.

 

[nexus73]

I never said you have to bill on time. Read the other 3 options. Those are all easy to hit.

I know what you’re saying. I’m just saying billing on time is easy. But on complexity you need 4 problem points to get to high risk medical decision making. How are you getting those points typically, for followups?

 

[ObsequiousAplomb]

I know what you’re saying. I’m just saying billing on time is easy. But on complexity you need 4 problem points to get to high risk medical decision making. How are you getting those points typically, for followups?

- psychosis
- agitation
- depression
- mania
- anxiety
- insomnia
- suicidal ideation
- homicidal ideation
- alcohol use disorder
- tobacco use disorder
- stimulant use disorder
- hypertension
- diabetes
- HLD
- chronic pain
- headache
- medication-related adverse effects
- monitoring of serum levels
- treatment non-adherence
- etc

If you can't find 4 points of problems from the above categories, does the patient still need to be in the hospital today?

 

[allantois]

- psychosis
- agitation
- depression
- mania
- anxiety
- insomnia
- suicidal ideation
- homicidal ideation
- alcohol use disorder
- tobacco use disorder
- stimulant use disorder
- hypertension
- diabetes
- HLD
- chronic pain
- headache
- medication-related adverse effects
- monitoring of serum levels
- treatment non-adherence
- etc

If you can't find 4 points of problems from the above categories, does the patient still need to be in the hospital today?

Are you managing their medical issues? If not, I don’t drink it should factor in MDM

 

[nexus73]

Are you managing their medical issues? If not, I don’t drink it should factor in MDM

our inpatient service will manage basic things, like ABx for uncomplicated UTI, or at least monitor like HTN. Or mildly abnormal electrolytes like K, Na. Or elevated wbc that are likely reactive. But most of that resolves after 1-2 days so it stops being a problem point pretty quickly.

 

[AD04]

Is there a document or something I can Google that has this information. Tbh it sounds foreign to me as a still resident just begining to moonlight

Read through this:

CPT & Reimbursement

www.aacap.org

Then supplement whatever missing information with the link from my Thursday post. 2021 changes only applies to outpatient so keep that in mind. So read the 2018 training manual as well.

Then look through old threads on billing codes.

If you don't understand, pay for a billing course. It'll be well worth it to know how to bill.

 

[jbomba]

If one is doing their own billing in an inpatient psychiatric hospital, is there a ballpark range of what a 99232 or 90792 should pay?

 

[BiscoDisco]

If one is doing their own billing in an inpatient psychiatric hospital, is there a ballpark range of what a 99232 or 90792 should pay?

I imagine this is very geographic dependent (like outpatient codes). I've be told bad payors are around 110, better payors closer to 160ish for 232.

For those more experienced, does this sound right?

 

[psychmd03]

I imagine this is very geographic dependent (like outpatient codes). I've be told bad payors are around 110, better payors closer to 160ish for 232.

For those more experienced, does this sound right?

Damn I wish I could get those for a 99232 the medicaid payors in the area (midwest) are $43 the 90833 is an extra 50-70 which is nuts it so much more. The privates will pay close to 90 for a 99232. Clearly I need to move