What is the difference in documentation between coding a 99235 (Critical Care, Evaluation and Management of the Critically Ill or Critically Injured Patient) and a 99236 (Critical Care, Evaluation and Management of the Critically Ill or Critically Injured Patient)?

Documentation Differences Between CPT Codes 99235 and 99236

The primary difference between CPT codes 99235 and 99236 is the level of medical decision-making complexity and time requirements, with 99236 requiring higher complexity decision-making and more documented time than 99235.

Understanding the CPT Codes

• CPT codes 99235 and 99236 are used for observation or inpatient hospital care services, including admission and discharge on the same date 1
• Both codes require comprehensive documentation but differ in complexity level and time requirements 1

Key Documentation Differences

Medical Decision-Making Complexity

• 99235 requires moderate complexity medical decision-making 1, 2
• 99236 requires high complexity medical decision-making, demonstrating more extensive evaluation, multiple treatment options, and higher risk of complications 2

Time Requirements

• 99235 typically requires 50 minutes of face-to-face time with the patient 1, 2
• 99236 typically requires 55-60 minutes of face-to-face time with the patient 2
• When billing based on time, documentation must clearly state the total time spent and confirm that more than half was spent in counseling or coordination of care 2

Documentation Elements

For 99235 (Moderate Complexity):

• Detailed history and physical examination 1
• Documentation of moderate complexity medical decision-making 1
• Multiple diagnoses or management options with moderate amount of data to be reviewed 2
• Moderate risk of complications, morbidity, or mortality 2

For 99236 (High Complexity):

• Comprehensive history and physical examination 1
• Documentation of high complexity medical decision-making 1, 2
• Extensive number of diagnoses or management options 2
• Extensive amount of data to be reviewed 2
• High risk of complications, morbidity, or mortality 2

Coding Best Practices

• Documentation must clearly demonstrate the elements that justify the level of service billed 1
• Insufficient documentation to support the complexity level is a common reason for claim denials 2, 3
• When documenting critical care services, clearly establish medical necessity and the nature of the critical illness 4
• Avoid using templates or macros without customizing them to the specific patient encounter 1

Common Pitfalls to Avoid

• Failing to document the specific time spent when billing based on time 2, 3
• Using copy-forward functionality without updating information, which can lead to "note bloat" and obscure key findings 1
• Insufficient documentation of the medical necessity for the level of service provided 1, 4
• Not clearly documenting the high-risk nature of neurological or other conditions that may not be obvious to auditors 4

Audit Considerations

• Medicare and other payers regularly audit these high-level codes 1
• Documentation should clearly support the level of service billed to withstand potential audits 1
• In 2014, nearly half of all E&M visits for Medicare patients were incorrectly coded, with 26% being upcoded and 14.5% being downcoded 1

By understanding these key differences and ensuring proper documentation, providers can appropriately bill for the level of service provided while minimizing the risk of claim denials or audit issues.