In 2012, SHM reported increasing numbers of hospital encounters coded for high-level evaluation and management services, as reported by the 2012 State of Hospital Medicine (SOHM) survey respondents. The 2014 SOHM report shows a solid continuation of this trend, with high-level CPT codes predominating in admission and discharge services by wider margins than ever before.

The 2014 report provides CPT code data from 173 hospitalist groups, who reported the number of inpatient admissions with CPT codes corresponding to Level 1, Level 2, or Level 3. Inpatient discharges have codes corresponding to either Level 1 or Level 2.

Compared to 2012, Level 3 admissions (CPT 99223) increased by 14% in 2014 and now account for 77% of all admissions (see Figure 1). Level 2 discharges (CPT 99239) have increased by 17% since 2012 and now account for 63% of discharges.

(click for larger image)Figure 1. High-level admissions and discharges, as percent of all admissions and discharges; groups serving adults onlySource: 2014 State of Hospital Medicine report

In 2014, SOHM added CPT code distribution data for observation care. Observation admissions and inpatient and observation subsequent care are also reported as Level 1, 2, or 3 by the corresponding CPT codes. Observation discharges, which have only one code level, are also reported, in addition to the three levels of same-day admit/discharge encounters.

The rate of Level 3 CPT codes reported for observation admissions, which was 72%, roughly approximated that of inpatient admissions. For subsequent care, Level 2 accounts for the majority of both observation and inpatient codes.

Despite the general predominance of Level 3 admissions and now Level 2 inpatient discharges, not all hospitalist groups deal equally in these higher billing evaluation and management services. Groups in the West region previously dominated the high-level encounters in both admissions and discharges; in 2014, the South took the lead in high-level admissions.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing.–Dr.Creamer

One factor that has consistently signaled lower rates of high-level coding, however, is academic status. A likely reason, as alluded to in a previous “Survey Insights” column, relates to the fact that residents’ time is not billable. This is particularly important in the discharge coding, in which the higher Level 2 code is strictly based on the statement by an attending that discharge services were personally provided for more than 30 minutes. Understandably, this happens less often when a resident’s education includes providing discharge services.

If attending face-to-face time is a major factor in the discharge coding differential, it does not explain where academic groups are missing the boat on the admission side, where residents’ documentation is incorporated by attendings—and can have a substantial effect on accurate billing. This assumes that academic groups are not treating far fewer sick patients, less comprehensively, across the board.

In my own public academic hospital, I see reviewing the required elements of the history and physical examination (H&P) as survival for our hospital and our mission, as well as an opportunity to educate residents simultaneously in patient interviewing skills and system-based practice.

But before I get too far into waxing altruistic, let me recognize another factor suggested by the SOHM report: I am not 100% salaried. That means thorough documentation and accurate coding directly impact my personal compensation.

The 2014 SOHM report shows, as it did in 2012, an inverse correlation between high-level admissions and percent salaried compensation. Although this relationship remains less clear in follow-ups and discharges, perhaps hospitalists pay more attention to coding criteria when it’s bread on the table…and if time permits.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

Academic Hospitalist Groups Lag Behind in Admissions, Discharges