Home By the Numbers Social admissions and prolonged services

Social admissions and prolonged services

How should you document, and what can you bill?

April 2020
coding questions

We are treating a 59-year-old with general cognitive decline who is currently uninsured. (His Medicaid application and hearing are pending.) While he has long depended on local homeless shelters, he can no longer maintain living in one on his own. The Salvation Army shelter where he has been staying sent him to the hospital.

My question: What CPT code should I use for what is a social admission and a patient whose status is outpatient in a bed?


When a patient fails to meet both InterQual criteria for inpatient admission and medical necessity to support observation placement, any care a treating physician provides may not be covered.

Patients who do not need hospital-level services would be better served as outpatients.

If your visit was within the purview of an initial hos
pital care visit (an H&P), you could try to bill an evaluation and management visit (CPT codes 9922–99223). That will work only if your documentation supports the visit requirements and you had a medically necessary reason for the service.

If your visit was subsequent to initial hospital care performed by another physician, try to bill a subsequent hospital care visit (99231–99233). Again, that would work only with a medically necessary reason.

Or if you were asked to evaluate the patient to help determine what community services may be most appropriate, document that request as well as your findings and the circumstances that brought the patient into the hospital. In that case, I’d recommend using an office/outpatient visit E/M code for a new patient at whatever level your exam documentation would support.

All that said, this might again end up being a visit that’s not payable because of the lack of medical necessity. And have your social services department reach out to the Salvation Army to help identify appropriate services for this patient. Patients who do not need hospital-level services would be better served as outpatients.

Billing prolonged services
We have an ongoing debate over billing for prolonged services for more than one visit within the hospitalist group on the same day. Per the CMS, documentation must reflect both the start and stop time on the primary code to support the additional time—and this is where we get stuck. Trying to make sure that documentation takes place is a challenge.

How and when can we report two visits within the same group on the same day, and what are those documentation requirements?

I’ll base my response on Medicare guidance, which may differ from CPT in some regards. Use the appropriate set of criteria for billing purposes.

Clinicians must have a medically necessary reason for a second daily visit—so it can’t just be part of a group protocol to see patients both morning and evening. They must also have medically necessary reasons for prolonged services at both visits. And Medicare pays for only one visit per day for a single physician. When two physicians from the same practice and specialty see a patient on the same calendar day, you must combine both their services and report the appropriate CPT code(s).

As for billing prolonged services: Document the total time of the evaluation and management visit plus the total time for the prolonged services component, along with the date of service. So yes, you must document start and end times. Here’s an example: Start: 3:00 p.m. End: 3:55 p.m. Total time of visit: 55 minutes on 3-15-20.

Once you determine the appropriate E/M code for the combined visits, check the typical time assigned to that code. You can find that time in the definition for that CPT code in the CPT Manual or in the tables included in the CMS Internet-Only Manual 100-4 (Claims Processing Manual), chapter 12, section 30.6.15.

For example, the typical time for a level II subsequent hospital visit is 25 minutes; the threshold time 
to be able to bill prolonged care is 55 minutes (25 
minutes plus a minimum of 30 minutes). In this example, the total time you can report for prolonged care 55 minutes.

If your system can bill only each individual physician visit entered on a given service date, one of the E/M visits (and one of the prolonged services reported) will likely be denied. In some practice, reporting prolonged services becomes a manual process.

And when billing prolonged services, keep the requirements for physician presence in mind. You may count only the duration of direct face-to-face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code.

In the hospital, you cannot bill any of the following as part of prolonged services: time spent reviewing charts or discussing the patient with housestaff when you’re not in direct face-to-face contact with the patient. You also can’t bill time for waiting for test results, changes in the patient’s condition, or the end of a therapy, or for use of facilities.

Unless you have been selected for medical review, you don’t need to send your medical record documentation with the bill. But you must have documentation in the medical record about the duration and content of the medically necessary E/M service and prolonged services you’re billing.

Finally, you may find two CMS MLN Matters articles helpful. One is MLN Matters MM5972 and the other is MM9905.

Critical care time
A question: Can we document critical care time in “approximate” minutes? I can argue both sides of that question, but I generally say it’s not sufficient. What do you think?

I would for sure steer clear of verbiage such as “approximate.” Information sent out by CPT and MACs certainly suggests that you need to report actual time spent when documenting critical care services.

Sue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience. Send all of your billing and coding questions to slewis56@q.com, and we may answer them in a future issue.

Published in the April 2020 issue of Today’s Hospitalist

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