How to Bill a High Level Inpatient Visit Like a Pro (and Maximize Your Reimbursements)
Last week, we reviewed how to bill a moderate level inpatient visit. This week, it’s time to take it to the next level—the high level (formerly, level 5). Whether you're a physician, nurse practitioner, or coder, understanding how to get this right is the key to getting the reimbursements you deserve.
What’s a High Level Inpatient Visit, Anyway?
In the hierarchy of hospital inpatient visits, a high level visit (CPT Code 99223 for initial encounters, 99233 for follow-ups) is the top dog. It’s reserved for those high-complexity cases that demand significant time and medical decision-making. Think seriously ill patients with multiple comorbidities, where the care you’re providing isn't just a regular check-up but a life-saving intervention.
We're talking:
- Critically unstable patients
- Multiple new and chronic conditions requiring constant attention
- Complex decision-making where the stakes are high
The Billing Basics: Know Your Criteria
For time-based billing, the magic numbers here are 75 minutes for initial encounters, and 50 minutes for follow-up encounters.
Then, there’s medical-decision making based billing, when time-based doesn’t make the cut. This is where the real action happens. To hit high, MDM must involve high-complexity decisions. You’re managing a ton of data, assessing serious risk factors, and juggling multiple treatment options. Think: "What could go wrong if I miss something? Pretty much everything."
Show Your Work on MDM
Just like with moderate visits, you’ll need to hit 2 out of 3 of the following categories to meet criteria for high. However, the detail of each category is more complicated.
High complexity of problems
To meet a high level, you’ll need to be addressing severe, life-threatening (or close to it) problem(s). Here’s the list:
- 1+ chronic illness with severe exacerbation, progression, or side effects
- 1+ acute illness that poses a threat to life or bodily function
Moderate amount of data reviewed
Unlike for moderate visits (which require 1 out of 3), for high level visits you must meet 2 out of 3 of the following criteria:
- Review of 3+ prior notes, unique tests, or ordering of tests
- Independent interpretation of tests
- Discussion of management with external physician/source
This is still very doable for inpatient encounters. The limiting factor tends to be either independent interpretation of tests, or discussion with an external physician/source. So, take note if you do either.
Moderate risk of complications
The patient must be at high risk for morbidity and mortality, as a result of their condition and treatment plan.
Just like with moderate, the risk of complications is determined at the provider’s discretion. If you think the patient’s prognosis is poor, and they are at high risk for complications, document it! (e.g., “The patient is at high risk for complications because…”).
Helpfully, some examples of high risk are provided. These include:
- Drug therapy requiring intensive monitoring for toxicity (e.g., serial labs)
- Emergency surgery
- Escalation of hospital care
- Decision not to resuscitate or de-escalate care
But, again, don’t feel beholden to this list alone!
Final Thoughts
Getting reimbursed properly for high-complexity inpatient visits is about documenting the complexity being and justifying the real risk of morbidity and mortality. You’re providing top-notch care, and you deserve to get paid for it. Mastering the nuances of billing high level visits ensures you're compensated for the life-saving work you’re doing—while staying off the auditor’s radar.
So, go ahead, document that extra layer of complexity, show your cognitive work, and make sure every minute you spend on the case is accounted for. You’re not just billing; you’re showing the true value of your expertise.