a brief review on coding for hospitalist, initial and subsequent codes with template for physical exam.

1. Healthcare IT
EHR Fraud
99223's and 99233's

2. 2 most common EHR documentation
practices used to commit fraud:
1. Copy and paste
2. Over-documentation/Up Coding

3. • Post payment reviews and audits are
increasingly prevalent
• Good documentation is the only defense for the
physician
• The auditor’s motto is “Not documented, not
done!”
In Today’s Regulatory Environment . . .

4. 99223
99222
99221
99220
99219
Initial Visit Codes
INP - OUTP
99233
99232
99231
99226
99225
F/U Visit Codes
INP - OUTP

5. it's not the quantity of documentation that
matters, it's the quality.

6. 1995 vs. the 1997E/M Guidelines
OPQRST (6 ELEMENTS)
STATUS OF 3 CHRONIC CONDITIONS
HPI
PE
general multi-system exam OR single
organ system examinations
(BULLET SYSTEM)

7. 99223
99222
99221
99220
99219
Initial Visit Codes
Observation
Inpatient
Lowest level, $102 and is worth 1.92 RVUs.
Moderate level, $138 and is worth 2.61 RVUs.
Higuest level, $204 and is worth 3.86 RVUs.
Moderate level, $102 and is worth 3.84 RVUs.
Highest level, is worth 5.25 RVUs.

8. Level E/M Code History Physical exam MDM Time
1 99221 Detailed Detailed Low 30
2 99222 Comprehensive comprehensive Moderate 50
3 99223 Comprehensive comprehensive High 70
Level​ E/M Code​ History​ Physical exam​ MDM​ Time​
1​ 99218 Detailed​ Detailed​ Low​ 30​
2​ 99219 Comprehensive​ comprehensive​ Moderate​ 50​
3​ 99220 Comprehensive​ comprehensive​ High​ 70​
Observation
Inpatient
Initial Codes - All three key components are required

9. History
CC
HPI
ROS
PFMSH
Detailed Comprehensive
4 HPI elements
1 1
4 HPI elements
10 Syst ROS2-9 Syst ROS
1 Complete

10. Physical Exam
Detailed
12 bullets from any
organ system
Comprehensive
At least 2 bullets from 9
organ systems
(Bullet system)
Constitutional
(1 bullet for three vital signs)
(1 bullet for general appearance)
Eyes
(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)
Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose)
(1 bullet for examination of oropharynx)
Neck
(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)
Respiratory
(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)
Cardiovascular
(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)
Gastrointestinal
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
Lymphatic
(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)
Skin
(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)
Psychiatric
(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)

11. Example Comprehensive
Vitals: 120/80, 88, 98.6 #1
General appearance: NAD, conversant #2
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag;
PERRLA #3 #4
HENT: Atraumatic; oropharynx clear with moist mucous
membranes and no mucosal ulcerations; normal hard and
soft palate #5 #6
Neck: Trachea midline; FROM, supple, no thyromegaly or
lymphadenopathy #7 #8
Lungs: CTA, with normal respiratory effort and no
intercostal retractions #9 #10
CV: RRR, no MRGs, no edema or varices #11 #12
Abdomen: Soft, non-tender; no masses or HSM #13 #14
Lymph nodes: No cervical or extremity lymphadenopathy
#15 #16
Skin: Normal temperature, turgor and texture; no rash,
ulcers or subcutaneous nodules #17 #18
Psych: Appropriate affect, alert and oriented to person,
place and time #19 #20
Example Detailed
Vitals: 120/80, 88, 98 . #1
General appearance: NAD, conversant #2
Neck: FROM, supple #3
Lungs: Clear to auscultation #4
CV: RRR, no MRGs; normal carotid upstroke
and amplitude without bruits #5 #6
Abdomen: Soft, non-tender; no masses or
HSM #7 #8
Extremities: No peripheral edema or
digital cyanosis #9 #10
Skin: no rash, lesions or ulcers #11
Psych: Alert and oriented to person,
place and time #12
12 bullets from any
organ system
At least 2 bullets from 9 organ systems

12. MDM
2/3
OVERALL MDM PROBLEM POINTS DATA POINTS RISK
LOW COMPLEXITY
2 2 LOW
MEDIUM COMPLEXITY
3 3 MODERATE
HIGH COMPLEXITY 4 4 HIGH

13. PROBLEM POINTS
Established problem, stable or improving 1
Established problem, worsening 2
New problem, with no additional work-up planned (maximum of 1) 3
New problem, with additional work-up planned 4
Hypertension – Stable
Hypothyroidism- Stable
Atrial fibrillation with RVR- Uncontrolled
COPD exacerbation- Uncontrolled
Acute Hyponatremia- New
Acute hypokalemia- New
Acute respiratory failure
Acute blood loss anemia

14. Data Reviewed Points
Review or order clinical lab tests 1
Review or order radiology test (CXR, CT, MRI, Cartoid US, Doppler) 1
Review or order medicine test (PFTs, EKG,V/Q, cardiac echo or cath) 1
Discuss test with performing physician (radiologist, ER, GI) 1
Independent review of image, tracing, or specimen 2
Decision to obtain old records 1
Review and summation of old records 2

15. Risk Level Presenting Problems Diagnostic Procedures Management
Low Risk
•2 or more self-limited or minor problems
•1 stable chronic illness
•Acute uncomp injury or illness (cystitis)
•PFTs, ABI, Echo
•Non-cardiovascular imaging
studies with contrast (barium
enema)
•Superficial needle biopsy
•ABG
•Skin biopsies
•Over the counter drugs
•Minor surgery, with no
identified risk factors
•Physical therapy
•Occupational therapy
•IV fluids, without additives
Each Risk level Requires only ONE of these elements in ANY of the three categories listedRISK LEVEL
CLINICAL EXAMPLE:
1. Patient with OA of the knees, severe pain, which is no longer controlled with tylenol. You examine the
patient and switch to OTC ibuprofen. No labs are reviewed. Admit for PT eval
OVERALL MDM​ PROBLEM POINTS​ DATA POINTS​ RISK​
LOW COMPLEXITY​ 2​ 2​ LOW​

16. Moderate
Risk
•1 or > chronic illness, with mild
exacerbation, progression, or side effects of
treatment
•2 or > stable chronic illnesses
•Undiagnosed new problem, with uncertain
prognosis, e.g., lump in breast
•Acute illness, with systemic symptoms
•Acute complicated injury, e.g., head injury,
with brief loss of consciousness
•Tests under stress (cardiac
stress test)
•Scopes without risk factors
•Deep needle or incisional bx
•Cardiac catheterization
•Obtain fluid from body
cavity, LP/thoracentesis
•Minor surgery
•Elective major surgery (open,
percutaneous, or endoscopic),
with no identified risk factors
•Prescription drugs
•Therapeutic nuclear medicine
•IV fluids, with additives
•Closed treatment of fracture
Clinical example: 78 yo M with hx of COPD and HTN, with severe SOB for
5 days, found to be in mild respiratory distress due to COPD exacerbation,
started on IV solumedrol and IV Ceftriaxone, his BP is stable
OVERALL MDM​ PROBLEM POINTS​ DATA POINTS​ RISK​
MEDIUM COMPLEXITY​ 3​ 3​ MODERATE​

17. Risk Level Presenting Problems Diagnostic Procedures Management
High Risk
•1 or > chronic illness, with severe
exacerbation or progression
•Acute or chronic illness or injury, which
poses a threat to life or bodily function,
e.g., multiple trauma, acute MI, PE,
severe respiratory distress, psychiatric
illness, with potential threat to self or
others, peritonitis, AKI
•An abrupt change in neurological status,
e.g., seizure, TIA, weakness, sensory loss
•Cardiac catheterization with
identified risk factors
•Cardiac EP studies
•Diagnostic endoscopies, with
identified risk factors
•Discography
•Emergency Hemodyalisis
•Elective major surgery (open,
percutaneous, endoscopic)
with risk factors
•Emergency major surgery
(open, laparoscopic)
•Parenteral controlled
substances (IV opioids)
•Drug therapy requiring
intensive monitoring for
toxicity
•Decision not to resuscitate, or
to de-escalate care because of
poor prognosis
Clinical example: 78 yo M with hx of COPD and HTN, with severe SOB for 5 days, found to be acute respiratory failure due to
COPD exacerbation, intubated, started on IV solumedrol and IV Ceftriaxone, his BP is stable, IV morphine for pain. CT angio
to r/o PE pending.
OVERALL MDM​ PROBLEM POINTS​ DATA POINTS​ RISK​
HIGH COMPLEXITY​ 4​ 4​ HIGH​

18. CC : Chest pain
HPI : The patient is a 65 year old male who comes w the CC of sudden onset(1) chest pain, which began
early this morning (2), described as “crushing”(3) and 9/10 intensity (4)
PMH : GERD and hypertension
FH . : Mother died at 78 of breast cancer, Father at 75 of CVA.
SH : Negative for tobacco abuse; consumes moderate alcohol; married for 39 years
ROS : 10 point ROS reviewed and are negative except as noted in HPI
Vitals: 120/80, 88, 98.6 (1)
General appearance: NAD, conversant (2)
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag (3); PERRLA (4)
HENT: Atraumatic (5), oropharynx clear with moist mucous membranes and no mucosal ulceration (6)
Neck: Trachea midline; FROM, supple (7), no thyromegaly (8) or lymphadenopathy of neck area(9)
Lungs: CTA(10), with normal respiratory effort and no intercostal retractions(11)
CV: RRR, no MRGs (12), no pedal edema (13)
Abdomen: Soft, non-tender(14); no masses or HSM (15)
Extremities: No deformities or extremity lymphadenopathy (16)
Skin: Normal temperature, turgor and texture; no rash, ulcers (17) or subcutaneous nodules (18)
Psych: Appropriate affect,(19) alert and oriented to person, place and time (20)
Plan: 1. Chest pain R/O ACS: Trop x3, lovenox 1mg/kg/BID, Morphine IV for pain, stress test and echo
2. Uncontrolled HTN: prn hydralazine, continue acei and metoprolol
3. Uncontrolled diabetes w hyperglycemia: glycemia protocol

19. Subsequent Visit Codes - 2/3 key components are required
Level​ E/M Code​ History​ Physical exam​ MDM​ Time​
1​ 99224 Focused Focused Low​ 15
2​ 99225 Expanded​ Expanded Moderate​ 25
3​ 99226 Detailed Detailed High​ 35
Level E/M Code History Physical exam MDM Time
1 99231 Focused Focused Low 15
2 99232 Expanded Expanded Moderate 25
3 99233 Detailed Detailed High 35
Observation
Inpatient

20. Subjective
ROS
PFMSH
1-3 pt HPI
No
No
HISTORY
(Subjective and ROS)
CC 1
Subsequent visits always follow up something from the day before or new
events that occurred overnight
1
1-3 pt HPI
1
No
1
4 pt HPI
Or Status
3 chronic/inactive prob
2-9
No

21. CC : Follow-up Shortness of breath
S: Persistent SOB, severe intensity (1), associated to
wheezing (2), not improving w RT TID (3), worse at night time
(4)
ROS
General--Negative for fatigue, weight loss, anorexia
Cardiovascular--Negative for CP, orthopnea, PND
Endocrine--Negative for polyuria, polydipsia, cold intolerance

22. 1-5 bullets from
At least 1 system
Example
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Lungs: CTA
CV: RRR, no MRGs
99231
Focused exam
99232
Expanded
exam
Example
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, nontender
Extremities: No edema
6 bullets from
1> systems
99233
Detailed exam
Example
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid
upstroke without bruits
Abd: Soft, NTTP; no masses or HSM
Extr: No edema or cyanosis
Skin: no rash, lesions or ulcers
Psych: AAOx3
12 bullets from any
organ system

23. MDM
2/3
OVERALL MDM PROBLEM POINTS DATA POINTS RISK
LOW COMPLEXITY
2 2 LOW
MEDIUM COMPLEXITY
3 3 MODERATE
HIGH COMPLEXITY 4 4 HIGH

24. CC : Follow-up Shortness of breath
S:
SOB overnight, severe, associated wheezing
Hyponatremia noted in AM labs
Persistent hyperglycemia in POCT
Tolerating diet, afebrile
ROS
General--Negative for fatigue, weight loss, anorexia
Cardiovascular--Negative for CP, orthopnea, PND​
Endocrine--Negative for polyuria, polydipsia
Or 10 point ROS done and negative except for HPI
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Neck: FROM, supple
Lungs: +wheezing, mild resp distress
CV: RRR, no MRGs; normal carotid
upstroke without bruits
Abd: Soft, NTTP; no masses or HSM
Extr: No edema or cyanosis
Skin: no rash, lesions or ulcers
Psych: AAOx3
Valid Alternatives:
1. No acute distress
2. No acute events overnight
Not valid Alternatives:
1. Doing well
2. In CT suit during my exam
3. much improved
Plan: 2/3 MDM : 4 PP + 4 DR + HIGH RISK
Acute Hypoxic resp Failure - uncontrolled
Acute COPD exacerbation- worsening
Hyponatremia – new
Diabetes w hyperglycemia- Uncontrolled
CT angio to rule out PE
CXR independently reviewed w/o acute findings
Continue IV solumedrol 125 BID, monitor for worsening
hyperglycemia, delirium,
Continue IV vancomycin and zosyn, monitor vanco
through daily due to risk for toxicity
Replace electrolytes as needed

25. Admission – Patient with shortness of breath and chest pain, comorbidities present, diagnosed with
congestive heart failure and known ischemic cardiomyopathy treated medically, IV meds given, complexity is
high.
CPT code 99223
Day 2 – Patient improved, meds changed to PO, home meds restarted, no invasive tests planned, continuing
to monitor.
CPT code 99232
Day 3 – Kidney function worsens, meds held and changed appropriately, concern for cardiac output being low,
nephrology consulted, situation worsened from prior day.
CPT code 99233
Day 4 – Echo reviewed, cardiac function worse than thought, thinking about right heart cath, dobutamine
started on floor, IV diuresis ongoing, discussed with consultants.
CPT code 99233
Day 4 – Situation improves, renal function stabilizes with inotropic support and renal recommendations,
breathing improved, meds regimen stable, labs and CXR stable, patient likely to be discharged in next few
days.
CPT code 99232
Not every day can be a 99233 day