Inpatient - Hospital care or Observation Care
Hospital or observation care codes are divided based on the initial visit, subsequent visit, and discharge visit.
Date: December 31, 2023
Morning - Admission: Mr. Sharma, a 65-year-old male, is admitted to the hospital with severe chest pain. The attending physician, Dr. Patel, evaluates him and suspects a heart condition. Dr. Patel documents an admission note detailing Mr. Sharma’s symptoms, medical history, and initial treatment plan. This admission note is then billed.
Evening - Progress Note: Dr. Patel visits Mr. Sharma again in the evening to assess his condition. He notes that Mr. Sharma’s chest pain has lessened due to the medication. Dr. Patel documents a progress note outlining the patient’s response to treatment and any changes made to the treatment plan. However, only the admission note from the morning is billed for this day.
Date: January 2, 2024 - Discharge: on January 2, 2024, Dr. Patel sees Mr. Sharma in the morning and makes a progress note. However, this progress note is not billed separately. Later in the evening, when Dr. Patel discharges Mr. Sharma, a discharge note is prepared and billed. So, for this day, only the discharge visit is coded and billed. This is in line with the usual practice where only the most significant visit (in this case, the discharge) is billed on any given day.
AI Modifier:
AI modifier is appended to H&P note done for admission purpose when the payor is Medicare.
The AI modifier is used to identify the principal physician of record during an inpatient admission. This modifier should only be used by the admitting or attending physician overseeing the patient’s care during a hospital or nursing facility admission.
This modifier can be appended with 99221 to 99223, 99304 to 99306, and critical care code when critical care was warranted at the time of admission.
Admission notes: an Admission Note, also known as an H&P (History and Physical) note, is a crucial part of a patient’s medical record. It documents the patient’s status, including their history and physical examination findings, the reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient’s care.
MD or DO can perform the admission independently and get billed.
NPPs can not perform the admission independently, they need cosign from the MD/DO
Subsequent Note (Progress Note): Progress notes are clinical notes made by healthcare professionals involved in a patient’s treatment and care. They contain clinical facts and medical reasoning about the care delivered to patients and the clinical events relevant to diagnosis and treatment. They are professional documents that communicate important information on a patient’s condition between multiple providers.
Progress note can be documented by NPP alone as well. No cosign from MD/DO are needed.
Discharge Note: A discharge note, also known as a termination, note or discharge summary, is a written summary held in the client’s chart of what happened during the time the client was in your care. It is often the primary mode of communication between the hospital care team and aftercare providers. It includes reasons for termination, symptoms at the time of intake, initial reasons for seeking treatment, diagnosis, treatment goals, modalities and interventions used, progress made during treatment, and recommendations for future mental health care needs.
Discharge can be billed independently by MD/DO. NPPs needs cosign by MD/DO.
Admission Note 1:
Date: 2024-07-04
Admitting Physician: Dr. John Doe, MD
Chief Complaint: Chest pain
HPI:
The patient is a 65-year-old male presenting with a 2-hour history of substernal chest pain radiating to the left arm. The pain is described as severe and crushing, associated with diaphoresis and nausea. The patient denies any previous history of similar symptoms.
ROS: Cardiovascular: Positive for chest pain. Respiratory: No dyspnea, no cough. Gastrointestinal: Nausea present, no vomiting.
Neurological: No headaches, no dizziness.
PFSH: Past Medical History: Hypertension, hyperlipidemia. Family History: Father had a myocardial infarction at age 70. Social History: Smoker, 1 pack per day for 40 years, occasional alcohol use.
Physical Examination:
Vital Signs: BP 150/90, HR 90, RR 18, Temp 98.6°F. Cardiovascular: S1, S2 normal, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no hepatosplenomegaly. Neurological: Alert and oriented, cranial nerves intact.
MDM:
EKG shows ST elevation in the anterior leads.
Troponin levels elevated.
Diagnosis: Acute myocardial infarction.
Plan:
Admit to the coronary care unit (CCU).
Start aspirin, clopidogrel, and heparin.
Consult cardiology for urgent catheterization.
Admission Note 2:
Date: 2024-07-04
Admitting Physician: Dr. Jane Smith, DO
Chief Complaint: Shortness of breath
HPI:
The patient is a 75-year-old female presenting with progressive shortness of breath over the past week. The patient reports orthopnea and paroxysmal nocturnal dyspnea. She denies any recent chest pain or fever.
ROS:
Cardiovascular: No chest pain, orthopnea present.
Respiratory: Shortness of breath, no cough.
Gastrointestinal: No nausea or vomiting.
Neurological: No dizziness or weakness.
PFSH:
Past Medical History: Congestive heart failure, atrial fibrillation.
Family History: Mother had chronic heart disease.
Social History: Non-smoker, no alcohol use.
Physical Examination:
Vital Signs: BP 140/80, HR 100, RR 22, Temp 98.4°F.
Cardiovascular: Irregular rhythm, S3 present.
Respiratory: Bibasilar crackles.
Abdomen: Soft, non-tender.
Extremities: 2+ pitting edema in lower extremities.
MDM:
Chest X-ray shows pulmonary congestion.
BNP levels elevated.
Diagnosis: Acute exacerbation of congestive heart failure.
Plan:
Admit to telemetry.
Start diuretics and oxygen therapy.
Monitor fluid status and electrolytes.
Admission Note 3:
Date: 2024-07-04
Admitting Physician: Dr. Alex Turner, MD
Chief Complaint: Abdominal pain
HPI:
The patient is a 50-year-old male with a 1-day history of severe abdominal pain localized to the right lower quadrant. The pain is constant and aggravated by movement. The patient reports associated nausea and anorexia.
ROS:
Gastrointestinal: Abdominal pain, nausea, no vomiting.
Cardiovascular: No chest pain, no palpitations.
Respiratory: No cough, no dyspnea.
Neurological: No dizziness, no headaches.
PFSH:
Past Medical History: Appendectomy, hypertension.
Family History: No relevant family history.
Social History: Non-smoker, occasional alcohol use.
Physical Examination:
Vital Signs: BP 130/85, HR 85, RR 18, Temp 99.1°F.
Abdomen: Tenderness in the right lower quadrant, rebound tenderness present.
Cardiovascular: S1, S2 normal.
Respiratory: Clear to auscultation bilaterally.
MDM:
Abdominal ultrasound suggests acute cholecystitis.
WBC count elevated.
Diagnosis: Acute cholecystitis.
Plan:
Admit to general surgery.
Start IV antibiotics.
Prepare for laparoscopic cholecystectomy.
Admission Note 4:
Date: 2024-07-04
Admitting Physician: Dr. Emily Johnson, DO
Chief Complaint: Fever and confusion
HPI:
The patient is an 80-year-old female presenting with a 2-day history of fever and confusion. The patient has been disoriented and unable to perform daily activities. There is no history of recent travel or sick contacts.
ROS:
General: Fever present.
Neurological: Confusion, no focal deficits.
Cardiovascular: No chest pain, no palpitations.
Respiratory: No cough, no shortness of breath.
PFSH:
Past Medical History: Type 2 diabetes, hypertension.
Family History: No relevant family history.
Social History: Lives alone, non-smoker, no alcohol use.
Physical Examination:
Vital Signs: BP 110/70, HR 90, RR 20, Temp 101.2°F.
Neurological: Disoriented to time and place, no focal neurological deficits.
Cardiovascular: S1, S2 normal.
Respiratory: Clear to auscultation bilaterally.
Abdomen: Soft, non-tender.
MDM:
Blood cultures pending.
Urinalysis suggests urinary tract infection.
Diagnosis: Urosepsis.
Plan:
Admit to medical ward.
Start broad-spectrum antibiotics.
Monitor vitals and mental status.
Admission Note 5:
Date: 2024-07-04
Admitting Physician: Dr. Michael Lee, MD
Chief Complaint: Severe headache
HPI:
The patient is a 45-year-old female presenting with a sudden onset of severe headache described as "the worst headache of her life." The pain is diffuse and associated with photophobia and nausea. The patient has no history of similar headaches.
ROS:
Neurological: Severe headache, photophobia.
Cardiovascular: No chest pain, no palpitations.
Respiratory: No cough, no dyspnea.
Gastrointestinal: Nausea present, no vomiting.
PFSH:
Past Medical History: Migraine headaches.
Family History: No relevant family history.
Social History: Non-smoker, no alcohol use.
Physical Examination:
Vital Signs: BP 145/95, HR 95, RR 18, Temp 98.6°F.
Neurological: Alert, oriented, photophobia present, no focal deficits.
Cardiovascular: S1, S2 normal.
Respiratory: Clear to auscultation bilaterally.
MDM:
CT scan of the head shows subarachnoid hemorrhage.
Lumbar puncture confirms elevated opening pressure.
Diagnosis: Subarachnoid hemorrhage.
Plan:
Admit to neurology intensive care unit (NICU).
Start nimodipine.
Consult neurosurgery.