How to Bill a Moderate Inpatient Visit Without Losing Your Sanity (or Money)

Welcome to the world of medical billing: where paperwork grows like weeds and the codes never seem to end.

If you're a healthcare provider trying to get paid for the work you actually do, you know the struggle of billing visits accurately. Today, we're diving into one of the most common inpatient codes - the moderate patient visit.

What’s a Moderate Visit?

A moderate visit (CPT code 99222, 99232) is for an inpatient patient visit that requires a moderate amount of time or decision-making. It’s the sweet spot: not as straightforward as Level 3, but also not as intense as a Level 5. CPT code 99222 is for new inpatient encounters, while CPT code 99232 is for follow-ups. These are the patients who come in with multiple chronic issues or an acute, complicated illness. It’s a delicate balance, but bill it wrong, and you’ll either leave money on the table or risk an audit.

Let’s break it down into digestible steps so you can nail that moderate visit each time.

Step 1: Know the Criteria (2024 Edition)

Thankfully, gone are the days where you need to satisfy specific criteria across medical history, review of systems, examination, and medical decision making.

In the past, you would need: a chief complaint, an extended history of present illness (HPI), a review of 2-9 systems (ROS), at least one pertinent past, family, or social history (PFSH), as well as a detailed exam, including  a range of 6-12 systems or body areas.

Now, you just need moderate medical decision making, or moderate time. Time is simple: spend at least 55 minutes during a new encounter, or 35 minutes during a follow-up. Medical decision making (MDM) is a bit more complicated.

Step 2: Master the Art of Moderate Medical Decision Making

MDM is the trickiest part, but also the most crucial. The best billers use a mix of time-based and MDM-based coding, depending on the encounter. To meet “moderate complexity,” you’ll need to address 2 out of 3 of the following:

Moderate complexity of problems

To meet a moderate level, you’ll need to be addressing multiple chronic problems, 1 acute problem, or 1 new problem with an uncertain prognosis. This last criteria is often overlooked. Abnormal lab tests? That’s a new problem with an uncertain prognosis. Spiking fevers? That’s a new problem with an uncertain prognosis. If there’s still a differential in play, and you are ordering tests to figure out the answer, you likely fall within moderate complexity of problems. Here’s the rest of the list:

• 1+ chronic illness with exacerbation, progression, or side effects
• 2+ stable chronic illnesses
• 1 undiagnosed new problem
• 1 acute illness with systemic symptoms

Moderate amount of data reviewed

You must meet 1 out of 3 of the following criteria, to qualify for moderate:

• Review of 3+ prior notes, unique tests, or ordering of tests
• Independent interpretation of tests
• Discussion of management with external physician/source

This is not overly challenging for inpatient encounters, where labs tend to be drawn daily and radiographs are common. For example, if you review the consultant’s note (1), the CBC (2), and the chem panel (3), you have already met criteria for moderate.

Moderate risk of complications

The patient must be at moderate risk for morbidity and mortality, as a result of their condition and treatment plan.

Importantly, risk of complications is determined solely at the provider’s discretion. If you think the patient’s prognosis is guarded, and they are at moderate risk for complications, document it! (e.g., “The patient is at moderate risk for complications because…”).

Helpfully, some examples of moderate risk are provided. These include:

• Prescription drug management
• Minor surgery with risk factors
• Elective major surgery
• Social determinants of health that limit treatment

But don’t feel beholden to this list alone!

Step 3: Watch Out for Pitfalls

• Underdocumenting: If you don’t write it down, the coder can’t bill it. All those clarification requests you get in your inbox? It’s because coders cannot interpret information that’s not written, even if it's obviously so. Make sure your documentation reflects the complexity of the visit.
• Overcoding: On the other hand, overestimate the complexity, and you risk an audit. If that happens, not only are you refunding payments, but you might also be flagged for further investigation. No thanks.
• Over reliance on EMR templates: Sure, it’s convenient, but templates can lead to missing critical info. Customize them to match the complexity of each visit.

Step 4: Use an Audit Tool

Last, but not least, there are tools out there that help you review documentation before submitting your bill. Think of it as spellcheck, but for your billing codes. Running your visit through one of these could save you a world of pain later on. Most of the popular EMRs have something integrated.

Wrapping it Up: Bill Smarter, Not Harder

Billing a Level 4 visit is about playing by the rules, but knowing which rules work in your favor. It’s the difference between getting fairly compensated and giving insurers free money. Remember: detailed documentation, mix of time and MDM, and efficient use of templates can go a long way.