January 29, 2021 | By Scott Kraft, CPMA, CPC
One of the big changes in the new E/M Documentation Guidelines for 2021 for office and outpatient service codes 99202-99215 is the new high-risk category of “Decision Regarding Hospitalization.”
As an auditor, the first thing I thought about were the situations in which a very sick patient presents to the office and is so ill that the rendering provider directs the patient immediately to the hospital for treatment. In many instances, these services weren’t supportable as level 5 codes due to deficiencies in the history and exam that fell short of requirements for those codes.
But we don’t have any history and exam requirements for these services in 2021 beyond what the provider considers to be clinically appropriate for patients. That led me to think about the circumstances where I believe the documentation meets the “Decision Regarding Hospitalization” standard for high risk.
First, I noted that the wording in the guidelines is not “Decision to Hospitalize the Patient,” but is “Decision Regarding Hospitalization.” From that, I believe that this risk factor can be appropriate when the ultimate result is something other than the patient being hospitalized.
The American Medical Association’s (AMA) guidance on the new risk factors endorses this, offering an example of a patient with advanced dementia and an acute condition that would ordinarily require hospitalization, but was not hospitalized because the treatment goal was palliative care. A second example is a psychiatric patient who has sufficient support at home to avoid hospitalization.
Here are the standards I would suggest applying when considering whether to apply the risk standard of Decision Regarding Hospitalization:
- Hospital level care is appropriate based on the patient’s clinical condition: The documentation should reflect a severity of the patient’s condition or factors such as the patient potentially not being able to manage his or her condition independently that suggests the patient is potentially clinically appropriate for the hospital, even if that is not the care setting that is ultimately chosen. If there is no circumstance by which hospital care is appropriate, there is no decision to make regarding hospitalization.
- The documentation shows the thought process around hospitalization: This incorporates the suggestions made by the AMA. If the patient is choosing palliative care as noted above, or desires the de-escalation of care for end of life purposes, that reflects a thought process and decision not to hospitalize. The provider’s strong feelings that hospital care is appropriate for the patient as documented in the record alongside a patient’s refusal to go would also meet this standard.
- Clinical factors are driving the decision making: I was once directed to the hospital because the setting in which I sought care didn’t offer radiology services after 7 pm. While I was stable, I was told that in order to have an X-ray I needed to go to the hospital. I don’t believe this would be a good example of high-risk decision regarding hospitalization.
- Medical Necessity of the case: Remember that medical necessity as reflected by the patient’s condition is the driving factor in code selection. Some issues that remain controversial under the new guidelines, such as whether sending the patient to an emergency room is considered hospitalization, can be addressed by describing the imminent risk to life or health the patient faces. Documentation of service time is another factor in 2021 for higher level services. But a patient who inquires about hospitalization when the provider does not believe the need exists in any fashion is not a case I’d recommend using this risk factor on.
As an auditor, I often tell providers that it is their documentation that is the driving factor in appropriate code utilization and it is important for them to describe the clinical picture of the case. For “Decision Regarding Hospitalization,” I think the insight into the reason the provider believes hospitalization is an appropriate consideration, the thought process into the decision-making between provider and patient, followed by the ultimate near- and or long-term decision that was made during the visit are the three key factors in determining the use of this risk factor.
Remember, the biggest change to the table of risk in 2021 is that the columns on severity of acute and chronic illness are no longer part of the table of risk and are only part of the column on number of diagnoses under active management. Hospitalization considerations in the setting of severe illness is one way to establish high risk when appropriate under the 2021 guidelines.